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: The correct answer is B, D, and E. Reorienting the client helps maintain their cognitive function. Approaching slowly minimizes agitation and builds trust. Maintaining a low-stimulation environment supports the client's well-being. A is incorrect as family support can be beneficial. C is unnecessary unless there are specific reasons.
Extract:
Question 2 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: The correct answer is A: The client is constantly talking. In bipolar disorder, during the manic phase, individuals often exhibit rapid speech, impulsivity, and excessive talking. This behavior is a hallmark of mania. The other choices are incorrect because expressing feelings of inferiority (
B) is more indicative of depression, memory loss (
C) could be a symptom of various conditions but not specific to mania, and sleeping over 10 hours a day (
D) is more characteristic of depression or sedation from medication.
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 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 5 of 5
A nurse is caring for a client who has a depressive disorder. The client states, 'I don’t always go to bed at night, so I get in trouble for falling asleep at work.' Which of the following interventions should the nurse recommend?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Keeping a sleep diary to promote a consistent sleep schedule is the most appropriate intervention. By tracking sleep patterns, the client and nurse can identify underlying issues impacting sleep and work together to establish a structured routine. This intervention promotes sleep hygiene and helps regulate the client's sleep-wake cycle, potentially improving sleep quality and work performance.
Summary for Incorrect Answers:
A: Taking a 1-hour nap every day may disrupt the client's circadian rhythm and worsen insomnia.
B: Exercising late in the day can increase alertness and make it harder for the client to fall asleep at night.
D: Discontinuing medication without medical guidance can be dangerous and may exacerbate the client's depressive symptoms.