ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
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 1 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: Reorientation (
B), slow approach (
D), and low stimuli (E) aid delirium management. Limiting family and rotating staff may increase confusion.
Extract:
Question 2 of 5
A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?
Correct Answer: A
Rationale: Identifying the grief stage tailors support, the priority. Normalizing anger, activity, and counseling follow assessment.
Question 3 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: Expressing concern prioritizes safety empathetically. Medication levels don’t address emotion, requests give false hope, contracts are unreliable.
Question 4 of 5
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?
Correct Answer: A
Rationale: Constant talking (pressured speech) indicates mania’s high energy. Inferiority and hypersomnia suggest depression, memory loss isn’t mania-specific.
Question 5 of 5
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
Correct Answer: A
Rationale: Comparing to a brother shows personal projection, indicating countertransference. Other statements are observational or boundary-related, not personal bias.