ATI RN
ATI Custom NUR 316 Fall 2023 1MHE Module 4 - 1st 5 units Questions
Extract:
A nurse is caring for a client who has schizophrenia.
Nurses' Notes.
Day 1 1230: A 38-year-old client who has schizophrenia is admitted.
Diagnosed 15 years ago.
Client reports, "I have been hearing voices again telling me to hurt myself.
I hear voices at nighttime so I am not sleeping well.”. Day 1 1730: Vital Signs.
Client consumed 35% of evening meal.
Client appears nervous but reports not hearing voices at this time.
Day 1 1930: Nurse enters client's room.
Client is standing on bed and states, "Do you see that man? He is telling me he is going to hurt me.”. Client pointing to corner of the room.
Client is talking to themselves and states, "I don't want to hurt myself.
Tell the voices to go away!" Nurse asks the client who they are talking to and states, "Tell me more about who is trying to hurt you.”.
Question 1 of 5
The nurse is reviewing the client's medical record.Select the "3" findings that require immediate follow-up by the nurse.
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Hallucinations, delusions, and insomnia are symptoms that indicate a potential mental health issue requiring immediate follow-up. Hallucinations and delusions suggest psychosis, while insomnia may indicate an underlying mental health condition or stress.
Choice A is a common developmental concern, not requiring immediate follow-up.
Choice E, appetite, is less urgent compared to symptoms indicating mental health issues.
Extract:
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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