ATI RN
ATI Mental Health 2023 II Questions
Extract:
Nurses' Notes
1100:
Client is alert and oriented x 4. The client exhibits positive self- esteem. No negativity noted during conversation. Preparing client for discharge to partial-hospitalization program.
1230:
Client requests smoked turkey club sandwich for lunch. Education regarding medications provided. Exhibit 2
Patient Data
Medications
Phenelzine
Ibuprofen
Acetaminophen
Patient Data
Question 1 of 5
When educating the client about their medication, the nurse should teach the client that there is risk for ___ due to ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. Action A (Hypertensive crisis) and B (Ingestion of tyramine) are correct because certain medications, like MAOIs, can interact with tyramine-rich foods leading to hypertensive crisis.
2. Potential condition C (Infection) is incorrect as it is not directly related to educating the client about medication risks.
3. Parameters to monitor D (Agranulocytosis) and E (Rhabdomyolysis) are incorrect as they are not typically associated with MAOI medication education.
Extract:
Physical Examination
Day 1 0900:
A client who has a urinary tract infection is admitted for treatment with IV antibiotics. The client is alert and oriented x3. Respirations are equal and unlabored bilaterally. S1 and S2 heart tones noted upon auscultation. Client has hearing loss and wears glasses. Abdomen is soft with suprapubic pain on palpation rated as a 4 on a scale of 0 to 10. Client reports three episodes of urinary incontinence. Bowel sounds active in all four quadrants. Able to move all extremities.
Vital Signs
Day 1 0915:
Temperature 37.3° C (99.1° F)
Heart rate 90/min
Respiratory rate 15/min
Blood pressure 130/76 mm Hg
Oxygen saturation 97% on room air
Day 1 1900:
Temperature 37.3° C (99.1° F)
Heart rate 99/min
Respiratory rate 16/min
Blood pressure 136/88 mm Hg
Oxygen saturation 98% on room air
Nurses' Notes
Day 1 1900:
The client is alert and is oriented to person, with confusion about time and place. Client is unable to focus. The client exhibits agitation upon assessment. Client states they do not remember coming to the facility, and they are late for a provider's appointment. Reorientation to environment initiates anxiety and worsens the agitation.
Question 2 of 5
Upon assessment, the nurse should recognize that the client is at risk for developing ___ as evidenced by the client’s ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
1. Delirium (
A) and Orientation (
B) are correct actions to take as they are common indicators of cognitive impairment and risk for adverse events.
2. Dementia (
C) is the potential condition the client is at risk for developing due to cognitive decline.
3. Monitoring Stroke (
D) is important as it can lead to cognitive impairments and increase the risk of developing dementia.
4. Monitoring Hearing Loss (E) is also crucial as it can impact communication and exacerbate cognitive decline.
Extract:
Diagnostic Results
Day 1 at 1530:
WBC count 7,700/mm3 (5,000 to 10,000/mm3)
Indicates Potential Improvement
Indicates Potential
Worsening
Hgb 14% (12% to 16%)
Hct 42% (37% to 47%)
Day 2 at 0600:
Lithium level 1.9 mEq/L (less than 1.5 mEq/L) Glucose level 90 mg/dL (74 to 106 mg/dL)
Vital Signs
Day 1 at 1600:
Temperature 37° C (98.6° F) Respiratory rate 18/min
Pulse rate 84/min
Blood pressure 114/64 mm Hg
Day 2 at 0800:
Temperature 36.9° C (98.4° F)
Respiratory rate 16/min
Pulse rate 88/min
Blood pressure 98/56 mm Hg
Medical History
Day 1 at 1500:
Bipolar disorder
Laparoscopic appendectomy at age 8 years old
Physical Examination
Day 1 at 1600:
Client reports mild nausea. Fine hand tremors noted. Lungs clear, bowel sounds active
Day 2 at 0630:
Client awake but appears fatigued. Movements and speech somewhat slowed. Lungs clear, abdomen soft with active bowel sounds. Client voided a large amount of dilute yellow urine. Uncoordinated gait noted when ambulating to bathroom. Client reports blurred vision and noted to frequently rub eyes. Client fell asleep prior to end of assessment.
.
Question 3 of 5
The nurse is reviewing the client’s medical record at 0830 on day 2 of admission. For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client’s condition.
| Options | Indicates Potential | Indicates Potential |
|---|---|---|
| Blurred vision | ||
| Blood pressure | ||
| Urine amount and color | ||
| Lithium level | ||
| Gait when ambulating |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
Blurred vision can indicate a potential worsening of the client's condition, as it may suggest neurological issues or medication side effects. Blood pressure can indicate potential improvement or worsening depending on the context. Urine amount and color are crucial indicators of renal function, so changes can indicate improvement or worsening. Lithium level monitoring is essential for clients on lithium therapy to prevent toxicity or ineffectiveness. Gait when ambulating is not provided in the choices, so it does not apply to this scenario.
Extract:
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years.
Client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day.
Client states, "I am so fat. No matter what I do, I can't get skinny or lose enough weight." The client's guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
The client has dry, pale skin that appears thin and fragile, with decreased turgor, especially in areas like the forearms or abdomen. The mucous membranes, including the mouth and lips, are dry and cracked. The urine output is reduced, with minimal amount of dark yellow urine.
Vital Signs
Heart rate 44/min
Respiratory rate 20/min
BP 86/50 mm Hg
Temperature 36.2° C (97.2° F)
Question 4 of 5
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options.The nurse should first address the client’s ___ followed by the client’s ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Anorexia nervosa; Parameter to Monitor: A, B.
Rationale: In anorexia nervosa, the client may be malnourished, leading to potential cardiovascular complications. Monitoring blood pressure and heart rate is crucial to assess cardiac function and overall health status. Addressing these parameters first allows the nurse to identify any immediate risks related to the client's condition. Monitoring temperature, vomiting, urine output, or skin turgor may be important in the overall assessment but addressing the cardiovascular status takes precedence in this scenario.
Extract:
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.
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
Diagnostic Results
Blood alcohol level (BAC) 310 mg/dL (0 to 50 mg/dL)
History & Physical
Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions. Cardiovascular: Normal sinus rhythm and pulses palpable. No history of Heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.
Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite. Genitourinary: Client reports no known problems.
Impression:
Relapse of alcohol use disorder. Plan:
Admit for alcohol use disorder and observe for alcohol withdrawal.
Question 5 of 5
A nurse in a mental health facility is admitting a client.Exhibits:A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.
Correct Answer: B,C,D,E,F
Rationale:
Correct
Answer: B, C, D, E, F
Rationale:
B: Client's recent consumption of alcohol should be followed up as it indicates potential relapse or withdrawal symptoms.
C: Blood alcohol level should be monitored to assess intoxication level or withdrawal risk.
D: Client's recent loss may trigger emotional distress or exacerbate alcohol use disorder symptoms.
E: Respiratory assessment is crucial due to potential respiratory depression associated with alcohol use.
F: Neurological assessment is needed to evaluate cognitive function and potential alcohol-related neurological impairment.
Summary:
A: Smoking history is not directly related to immediate alcohol use disorder management.
G: Cardiac assessment is not a priority unless there are specific cardiac symptoms present.