ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Nurse’s Notes
2000:
Client presents to the triage desk accompanied by a friend. The client states, “I need help. I was raped about an hour ago.” The client’s friend states, “I think they may have been drugged.” Allergies: penicillin, doxycycline Physical exam: General: exhibits anxiety Respiratory: breath sounds clear Cardiovascular: S1, S2, no murmur Abdomen: soft, mildly tender Skin: bruising to upper arms bilaterally, broken fingernails
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Vital signs
2015:
Blood pressure: 128/88 mm Hg
Heart rate: 80/min
Respiratory rate: 16/min
Temperature: 37°C (98.6°F)
Weight: 67.1 kg (147.9 lbs.)
Question 1 of 5
The nurse is continuing to care for the patient in the emergency department.Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.
Correct Answer: A,B,E,F
Rationale: The correct answer choices (A, B, E, F) are potential complications of the client's diagnostic results in the emergency department. Nausea and vomiting (
A) can indicate an adverse reaction to medication or underlying condition. Confusion (
B) may result from electrolyte imbalances or neurological issues. Amnesia (E) could be a sign of mental status changes due to the diagnostic results. Respiratory depression (F) might indicate a worsening respiratory condition.
Choices C and D are unlikely complications related to diagnostic results, as tachycardia (
C) is more likely a physiological response to stress or pain, while hypothermia (
D) is not typically associated with diagnostic tests.
Question 2 of 5
The nurse is continuing to care for the patient in the emergency department.Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.
Correct Answer: A,B,E,F
Rationale: The correct answer choices (A, B, E, F) are potential complications of the client's diagnostic results in the emergency department. Nausea and vomiting (
A) can indicate an adverse reaction to medication or underlying condition. Confusion (
B) may result from electrolyte imbalances or neurological issues. Amnesia (E) could be a sign of mental status changes due to the diagnostic results. Respiratory depression (F) might indicate a worsening respiratory condition.
Choices C and D are unlikely complications related to diagnostic results, as tachycardia (
C) is more likely a physiological response to stress or pain, while hypothermia (
D) is not typically associated with diagnostic tests.
Extract:
Question 3 of 5
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?
Correct Answer: C
Rationale: The correct answer is C: Improvement in manifestations of depression. Electroconvulsive therapy is primarily used to treat severe depression.
Therefore, improvement in depressive symptoms indicates the treatment's effectiveness. Reduced frequency of seizures (
A) is not relevant to ECT. Reduced panic attacks (
B) and decreased fear of heights (
D) are not direct indications of ECT effectiveness. Make sure to monitor for potential side effects of ECT such as memory problems.
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:
Correct Answer: B, C, E
Rationale:
B: Installing sensor devices on outside doors will alert the caregiver if the client tries to wander at night, preventing falls and ensuring safety.
C: Positioning the mattress on the floor reduces the risk of injury if the client falls out of bed during the night.
E: Putting locks at the top of doors can prevent the client from wandering outside at night, reducing the risk of falls and injuries.
Incorrect
Choices:
A: Placing the client in a reclining chair may not address the wandering issue and could lead to discomfort or pressure ulcers.
D: Encouraging physical activity prior to bedtime may increase restlessness and agitation, potentially worsening the wandering behavior.
Other options are not provided, but it's important for the caregiver to maintain a safe environment and provide appropriate supervision for the client.
Question 5 of 5
A nurse is caring for a group of clients in a mental health facility. Which of the following is a task that can be delegated to assistive personnel?
Correct Answer: B
Rationale: The correct answer is B. Sitting with a client who has anorexia during mealtimes can be delegated to assistive personnel as it involves providing emotional support and encouragement. This task does not require specialized nursing skills and can be safely performed by assistive personnel under the supervision of a nurse.
Choices A, C, and D involve complex assessments, critical thinking, and specialized skills that should be performed by a licensed nurse. Reinforcing coping mechanisms, discussing relapse prevention, and administering medications all require nursing judgment and expertise. Delegating these tasks to assistive personnel could compromise the quality of care and put the client's safety at risk.