ATI RN
ATI Mental Health 2023 II Questions
Extract:
Vital Signs
Admission, 1600:
Temperature 36.1° C (97° F)
Blood pressure 98/66 mm Hg
Heart rate 76/min
Respiratory rate 10/min
Pulse oximetry 95% on room air
Day 2, 0800:
Temperature 37.3° C (99.1° F)
Blood pressure 198/86 mm Hg
Heart rate 116/min
Respiratory rate 22/min
Nurses' Notes
Client brought in by a family member who states that the client has been drinking "nonstop since the death of the client's parents 3 months ago."
Client has a history of alcohol use disorder for over 20 years.
Client attended inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client's family member, the client has been unable to cope with the sudden death of their parents.
Client is currently unemployed after being laid off.
Client's family member states, "Everything combined caused the drinking to start again." Family member estimates the client's last drink was 2 hr ago.
Day 2, 0800:
Client is in the bathroom vomiting. Assisted the client with oral feeding.
Question 1 of 5
The nurse should first administer ___ followed by administering ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Nausea/Vomiting; Parameter to Monitor: Blood pressure, Heart rate.
Rationale: Metoclopramide is commonly used to treat nausea/vomiting, making it a suitable initial choice. Propranolol can be administered to manage symptoms of anxiety or tremors that may occur. Monitoring blood pressure and heart rate is crucial due to potential side effects of these medications on cardiovascular function. Methadone, a pain medication, is not appropriate for this scenario. Propanolol is misspelled and not relevant.
Extract:
Vital Signs
Admission, 1600:
• Temperature 36.1° C (97° F)
• Blood pressure 98/66 mm Hg
• Heart rate 76/min
• Respiratory rate 10/min
• Pulse oximetry 95% on room air
Day 2, 0800:
• Temperature 37.3° C (99.1° F)
• Blood pressure 198/86 mm Hg
• Heart rate 116/min
• Respiratory rate 22/min
Hospital day 5,0800:
• Temperature 36.1° C (97° F)
• Blood pressure 128/66 mm Hg
• Heart rate 74/min
• Respiratory rate 12/min
Nurses' Notes
Client brought in by a family member who states that the client has been drinking "nonstop since the death of the client's parents 3 months ago."
Client has a history of alcohol use disorder for over 20 years.
Client attended inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client's family member, the client has been unable to cope with the sudden death of their parents.
Client is currently unemployed after being laid off.
Client's family member states, "Everything combined caused the drinking to start again." Family member estimates the client's last drink was 2 hr ago.
Day 2, 0800:
Client is in the bathroom vomiting. Assisted the client with oral feeding and he has a good appetite.
He resolves to limit his alcohol intake moving forward. He has currently accepted the news about his parents demise and is attending group therapy.
Question 2 of 5
A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.
Correct Answer: A,B,D,E
Rationale: The correct answer includes appetite, movement through stages of grief, participation in group therapy, and client resolving to limit alcohol consumption. These findings indicate progress as they show physical, emotional, social, and behavioral improvements. Monitoring appetite reflects physical well-being. Movement through grief stages indicates emotional healing. Participation in group therapy signifies social engagement. Resolving to limit alcohol consumption demonstrates behavioral change towards healthier choices.
Choices C and F-G are incorrect as cognition alone doesn't capture holistic progress, and the remaining options lack the diverse indicators of progress seen in the correct answer.
Extract:
Question 3 of 5
A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Report the information to local authorities. This is the appropriate action to ensure the safety of the client's partner. Reporting to local authorities is crucial in cases where harm to others is imminent. Notify the provider (choice
A) prolongs the risk, avoiding reporting due to confidentiality (choice
B) is unethical, and telling risk management (choice
C) may not lead to immediate intervention. Reporting to local authorities is the most direct and effective way to protect the potential victim.
Question 4 of 5
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Remain with the client for 1 hr after meals. This action is important as it can help prevent purging behaviors and provide emotional support. By staying with the client, the nurse can monitor for any signs of distress, offer reassurance, and help the client cope with any negative feelings that may arise after eating. Weighing the client every other day (
B) may exacerbate anxiety and lead to further disordered eating behaviors. Offering snacks when hungry (
C) may not address the underlying emotional issues associated with binge eating. Planning a menu with the client (
D) may be overwhelming and potentially trigger binge episodes.
Question 5 of 5
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
Correct Answer: D
Rationale: The correct answer is D: Snap a rubber band on your wrist when you think about checking the locks. This technique is effective in thought stopping because the physical sensation of snapping the rubber band serves as a distraction and interrupts the obsessive thought pattern related to checking the locks. By associating the act of snapping the rubber band with the thought, the client can become more aware of their thoughts and break the cycle of compulsive behavior.
Incorrect
Choices:
A: Asking a family member to check the locks does not address the underlying issue of obsessive thoughts and may reinforce dependency.
B: Focusing on abdominal breathing is a relaxation technique, not a thought-stopping technique.
C: Keeping a journal may help track behavior but does not actively interrupt the obsessive thoughts.