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: GHB, suspected here, causes nausea/vomiting (
A), confusion (
B), amnesia (E), and respiratory depression (F) due to CNS depression. Tachycardia (
C) isn’t typical (bradycardia is), and hypothermia (
D) isn’t linked.
Extract:
Question 2 of 5
A nurse is caring for a client who is experiencing a situational crisis following the sudden loss of their adolescent child. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The first and most critical action for a nurse caring for a client in a situational crisis, especially after the sudden loss of a child, is to determine if the client has thoughts of self-harm. A situational crisis can lead to overwhelming emotions, which may result in suicidal ideation or attempts. Ensuring the client's safety is the top priority, and immediate intervention is required if there is any indication of self-harm thoughts. Teaching coping skills, identifying support, and planning follow-ups are important but secondary to ensuring immediate safety.
Question 3 of 5
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
Correct Answer: A
Rationale: Demonstrating orientation to person, place, and time suggests cognitive stability, indicating the client may no longer pose a risk, allowing restraint removal. Refusal of medication or threats of self-harm suggest ongoing risk, and following commands alone isn’t sufficient without broader assessment.
Question 4 of 5
A nurse is caring for a client with depression. Which intervention should be prioritized? (Hypothetical based on context)
Correct Answer: A
Rationale: Monitoring for suicidal ideation is the priority in depression care due to the high risk of self-harm, ensuring safety before other interventions. Isolation worsens depression, sedatives may mask symptoms, and relaxation is secondary to safety.
Question 5 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: ECT is primarily used for severe depression, and improvement in depressive symptoms (e.g., mood, energy) is the key effectiveness indicator. Seizure frequency isn’t reduced (ECT induces them), panic attacks and phobias aren’t primary targets.