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Mental Health ATI - Assessment A Exam Questions with Solutions
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Mental Health ATI - Assessment A ExamQuestions with Solutions
A nurse in mental health facility observes a client who is experiencing panic
level of anxiety. Which of the following actions should the nurse take first? -
-Accompany the client to a quiet room. (Greatest risk for this client is injury
due to severe anxiety. Therefore, first action nurse should take is to stay
with client and bring him to a room with minimal stimuli.)
-A nurse is obtaining a history and physical on a client who presents to the
emergency department of a mental health facility. The nurse recognizes
which of the following assessment findings as being consistent with PTSD?
(Select all that apply) - -Distressing dreams
Difficulty concentrating
Exaggerated startle response
-A nurse is providing teaching to a client who has a new prescription for
haloperidol. Which of the following side effects should the nurse instruct the
client to report to the provider? - -Shuffling gait. (Clinical findings of
pseudoparkinsonism such as shuffling gait may occur 5hr - 30 days after
beginning treatment. The client should notify the provider who might
prescribe an anti parkinsonism agent.)
-A home health nurse is assessing an older adult client who lives alone.
Which of the following findings should indicate to the nurse that the client is
experiencing delirium? - -Sudden onset. (Clients usually develop delirium
suddenly over hours to days.)
-A nurse is caring for a client receiving imipramine for depression. For which
of the following adverse effects should the nurse monitor? - -Urinary
retention.
-A nurse is providing care for a client who has bipolar disorder and is
experiencing acute mania. Client's morning lithium level is 1.5 mEq/L. Which
of the following additional laboratory data has the highest priority?
a) Serum erythrocyte sedimentation rate 18 mm/hr
b) Hemoglobin 15 g/dL
c) serum T4 5 mcg/dL
d) Serum sodium 125 mEq/L - -Serum sodium 125 mEq/L (In the presence of
low sodium levels, renal excretion of lithium is reduced and client is at risk
for lithium toxicity. Therefore, this finding is highest priority because it places
client at greatest risk for injury.)
, -A nurse is caring for a client who has a history of substance use and was
involuntarily admitted to a mental health facility. When the nurse attempts
to administer oral lorazepam, the client refuses to take the medication and
becomes physically aggressive. Which of the following actions should the
nurse take? - -Do not administer the lorazepam. (Clients who are
involuntarily admitted retain the right to refuse treatment.)
-A nurse is developing a discharge plan for a client who has a history of
gambling dependency and includes participation in support group. The nurse
should tell the client that which of the following is the purpose of attending a
support group? - -Provide assurance that others have a similar problem.
(Participating in a support group with other individuals who have similar
problems will show the client that he is not the only one with this problem.
The client can learn alternative ways to solve problems that other members
of the group have also experienced.)
-A nurse is caring for a client who is deaf and is scheduled to have
electroconvulsive therapy (ECT). Provider needs to explain procedure to
client in order to obtain informed consent. Which of the following actions
should the nurse take? - -Request a professional interpreter to translate.
-Nurse is planning a teaching session regarding the code of ethics for
registered nurses. Which of the following should the nurse include in the
eaching? - -Right to treatment ensures individualized care.
-Nurse is caring for four clients in an inpatient mental health facility. Which
of the following clients can give informed consent? - -A 35-year-old who has
major depressive disorder.
-A nurse is caring for client whose child recently died in a motor vehicle
crash and states, "I just want to join him." Which of the following is the
nurse's priority response? - -"Are you thinking about harming yourself?"
(Greatest risk is self-injury; priority is therefore to ask client if she has plans
for self-harm)
-A nurse is assessing a client in the ED. Client appears agitated, his blood
pressure is 152/94 mm Hg, his HR is 104/min, and his pupils are dilated. The
nurse should suspect intoxication with which of the following substances? - -
Cocane (cocaine intoxication causes tachycardia, elevated BP, dilated pupils,
and agitation. These physiological findings suggest cocaine intoxication).
-A nurse is caring for a client who has schizophrenia and is prescribed
risperidone. Which of the following laboratory tests should the nurse
monitor? - -Blood glucose (risperidone can cause diabetes mellitus to
develop; therefore, nurse should plan to monitor client's blood glucose level
when taking this medication)
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