ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is admitting an older adult client who was transferring from another facility. The nurse notes pressure ulcers on the clients Coccyx and abrasions around both wrists which of the following actions should the nurse take to address suspicion of elder abuse?
Question 1 of 5
Which actions should the nurse take to address suspicion of elder abuse?
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
Extract:
A nurse is caring for a client
History and Physical
Day 1,0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean, appears to be listening to unseen others. Skin turgor poor.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
Vital Signs
Day 1, 0905:
Temperature 37.1° C (98,8° F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Question 2 of 5
Select the 4 findings that require immediate follow up
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Hallucinations (
A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (
B) could signify a cardiac problem. Disrupted sleep patterns (
C) may indicate underlying health conditions. Reduced skin turgor (
D) can signal dehydration or malnutrition.
Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.
Extract:
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer, Client states that this person has never told them to do anything: they
just stare and smile.
Question 3 of 5
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
Extract:
The nurse continues to care for the client.
History and Physical
Day 1, 0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
Question 4 of 5
Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness.
Therefore, the combination of mania and euphoric mood is indicative of a manic episode.
Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.
Extract:
The nurse continues to care for the client.
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums of
money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer. Client states that this person has never told them to do anything: they
just stare and smile.
Day 1, 1015:
Client's erratic behavior continues with loud outbursts. Continues to get out of bed and pace
around the unit. Prescription received to admit client to inpatient mental health unit.
Question 5 of 5
A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.
| Potential Prescription | Anticipated | Contraindicated |
|---|---|---|
| Encourage the client to avoid napping during the day. | ||
| Place the client in a room away from the nurses' station. | ||
| Weigh the client each day | ||
| Provide the client with high-calorie fluids every hour. |
Correct Answer: A,D
Rationale: Anticipated prescriptions include avoiding naps (to regulate sleep) and providing high-calorie fluids (for nutrition). Contraindicated prescriptions include isolating the client (which may worsen agitation) and daily weighing (unnecessary unless monitoring weight gain/loss).