ATI RN Mental Health
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Free ATI RN Mental Health Questions
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?
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Associative looseness
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Expressive affect
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Ambivalence
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Echolalia
Explanation
The Correct Answer is:
Echolalia
Explanation:
Echolalia is a common characteristic of autism spectrum disorder (ASD). It refers to the repetition or mimicry of words or phrases that the client hears, often without understanding their meaning. This behavior can serve as a way to communicate or self-regulate but is often considered a speech or language impairment in individuals with ASD.
Why the other options are incorrect:
Associative looseness
Associative looseness is a symptom often seen in psychotic disorders, such as schizophrenia, where thoughts and speech become disconnected or fragmented. This is not a typical finding in autism spectrum disorder.
Expressive affect
Expressive affect refers to the outward display of emotions or facial expressions. In ASD, individuals may have difficulty with social communication and may show limited expressive affect, but it is not a defining feature of the disorder.
Ambivalence
Ambivalence involves having mixed or contradictory feelings about something. This is not a key symptom of autism spectrum disorder, where social communication difficulties and repetitive behaviors are more prominent. Ambivalence may appear in other mental health conditions but not specifically in ASD.
A nurse is providing discharge teaching to a client with a new prescription for phenelzine (MAOI). The nurse should instruct the client to avoid which of the following foods when taking this medication?
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Cottage cheese
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Shellfish
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Salami
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Frozen peas
Explanation
The Correct Answer is:
C. Salami
Explanation:
Phenelzine is a monoamine oxidase inhibitor (MAOI), and clients taking MAOIs must avoid foods that are high in tyramine. Tyramine is an amino acid that can cause dangerous increases in blood pressure when consumed with MAOIs. Salami is a type of cured meat that contains high levels of tyramine and should be avoided.
Why the other options are incorrect:
A. Cottage cheese
Cottage cheese is a dairy product that is low in tyramine and generally safe to consume with MAOIs, although aged cheeses should be avoided due to their higher tyramine content.
B. Shellfish
Shellfish does not contain high levels of tyramine and is safe to eat when taking MAOIs.
D. Frozen peas
Frozen peas are not a high-tyramine food and can be safely consumed while on MAOIs.
A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?
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“I take care of my parent, who has Wernicke–Korsakoff syndrome.”
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“My boss fired me due to my frequent absence.”
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“I have a sibling who attends Al-Anon.”
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“My friends frequently drink alcohol, so I do not see them anymore.”
Explanation
Explanation
Correct Answer: C. “I have a sibling who attends Al-Anon.”Al-Anon is a support group designed for family members of individuals with alcohol use disorder. Having a sibling who attends Al-Anon indicates the presence of an informed, supportive family member who understands addiction and recovery. This reflects an available support system that can provide emotional encouragement, education, and stability, which are important factors in recovery.
A nurse is caring for a client who states, “Life is hopeless. I do not want to live anymore.” Which of the following actions should the nurse take first?
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Help the client identify what is worth living for in their lives.
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Ask the client if they are planning to hurt themselves.
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Reconnect the client with supportive family and friends.
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Explore the client’s feelings of hopelessness.
Explanation
Explanation
Correct Answer: B. Ask the client if they are planning to hurt themselves.This statement indicates hopelessness and possible suicidal ideation, which requires immediate safety assessment. The nurse’s first priority is to determine whether the client has intent, a plan, or means to harm themselves. Directly asking about self-harm is essential and does not increase suicide risk; instead, it allows for timely intervention and protection. Exploring feelings, identifying protective factors, and reconnecting support are important steps, but they must occur after assessing immediate suicide risk.
A nurse is caring for a client who is in physical restraints. Which of the following actions should the nurse take?
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Document the interventions used before applying restraints.
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Obtain a prescription to renew the restraint prescription every 48 hr.
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Secure the client in bed by tightly tucking in sheets.
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Delegate assistive personnel to check on the client regularly.
Explanation
Explanation
Correct Answer: A. Document the interventions used before applying restraints.Before applying physical restraints, the nurse must attempt and document less restrictive interventions, such as verbal de-escalation, environmental modification, or diversion. Documentation is required to demonstrate that restraints were used as a last resort and were necessary to protect the client or others.
Restraint prescriptions must be renewed much more frequently than every 48 hours, tightly tucking sheets is unsafe and not an approved restraint method, and although assistive personnel may help observe the client, the nurse remains responsible for ongoing assessment, monitoring, and documentation of restrained clients.
A nurse in a mental health facility is admitting a client!
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.
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: Clierk reports weight loss over the past 3 months and minimal appetite.
Genitourinary: Client reports no known problems.
Impression:
Relapse of alcohol use disorder.
Plane
Admit for alcohol use disorder and observe for alcohol withdrawal.
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)
Complete the following sentence by using the lists of options.
The client is at risk for developing ________ as evidenced by the client’s ________.
- Dysphoria and gastrointestinal assessment
- Alcoholic cardiomyopathy and blood alcohol level
- Alcohol withdrawal and history of alcohol consumption
- Dysphoria and blood alcohol level
Explanation
Explanation
Correct Answer: C. Alcohol withdrawal and history of alcohol consumptionThe client is at risk for alcohol withdrawal due to a long history of alcohol use disorder combined with recent cessation after heavy, prolonged drinking. The history of chronic alcohol consumption and the last drink occurring only 2 hours ago place the client at high risk for withdrawal as blood alcohol levels decline. Alcohol withdrawal can begin within hours and progress to seizures or delirium tremens, making early identification and monitoring essential.
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
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Ask the client to describe the situation.
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Give the client a bed bath prior to physical examination.
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Discuss self-defense techniques with the client.
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Inform the client photographs of injuries are required for a police report.
Explanation
The Correct Answer is:
D. Inform the client photographs of injuries are required for a police report.
Explanation:
In cases of sexual assault, it is important to preserve evidence, and photographs of injuries may be needed for legal purposes. The nurse should inform the client that photographs may be taken, but should also ensure that the client’s rights and dignity are maintained. The decision to have photographs taken should be explained to the client, and their consent should be obtained before proceeding. However, the nurse should never pressure the client into participating if they are not comfortable with it.
Why the other options are incorrect:
A. Ask the client to describe the situation.
The nurse should not immediately ask the client to describe the assault unless the client is ready to share. It is essential to avoid putting the client in a position where they feel forced to relive the trauma. The nurse should provide a safe space for the client to speak when they are ready, and offer support through appropriate channels, such as a counselor or social worker.
B. Give the client a bed bath prior to physical examination.
The client should not be bathed before a physical examination to preserve evidence. Bathing could remove potential forensic evidence that may be needed for a police report. The nurse should ensure that the client is not washed, and care should be taken to preserve any physical evidence, including clothing or bodily fluids.
C. Discuss self-defense techniques with the client.
While self-defense may be important to discuss at a later time for prevention, it is not an immediate priority during the acute care phase. The focus should be on the client’s immediate safety, physical and emotional well-being, and providing the necessary care for the assault.
A patient is prescribed 80 mg/day of Venlafaxine, administered twice daily. If Venlafaxine is available in 40 mg tablets, how many tablets should be given per dose?
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2 tablets
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3 tablets
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1 tablet
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4 tablets
Explanation
The Correct Answer is:
A. 2 tablets
Explanation:
The prescribed dose is 80 mg/day, administered twice daily. This means the patient should take 40 mg per dose. Since each tablet contains 40 mg, the patient should take 2 tablets per dose (40 mg × 2 = 80 mg).
Therefore, the nurse should administer 2 tablets per dose to meet the prescribed dosage.
A nurse is reviewing the medical record of a client who has a new prescription for selegiline transdermal. Which of the following findings should the nurse identify as a contraindication for administration of this medication to the client?
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Drinks a glass of orange juice daily
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Takes St. John’s wort daily
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Has a history of gastric reflux
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Has a history of cholelithiasis
Explanation
Explanation
Correct Answer: B. Takes St. John’s wort dailySelegiline is a monoamine oxidase inhibitor (MAOI). St. John’s wort has serotonergic properties and can significantly increase serotonin levels. When combined with an MAOI, this interaction places the client at high risk for serotonin syndrome, a potentially life-threatening condition characterized by autonomic instability, neuromuscular abnormalities, and altered mental status. Because of this serious interaction, concurrent use of St. John’s wort is a strict contraindication to selegiline therapy, and the nurse must withhold the medication and notify the provider.
A nurse is caring for a client.
Vital Signs
Nurses' Notes
Day 1, 1000:
Client is admitted to the emergency department via ambulance. Client was found in a car. Emergency medical services (EMS) reports that client was unresponsive and had used needles in their car. Pupils constricted bilaterally and sluggish. Client does not respond to commands. Respirations are shallow. Heart rhythm is regular. Abdomen is distended, bowel sounds hypoactive. Client grimaces to vigorous sternal rub.
Vital Signs
Day 1, 1000
Temperature 36° C (96.8° F)
Heart rate 56/min
Respiratory rate 8/min
Blood pressure 90/56 mm Hg
Oxygen saturation 89% on room air
Select the 5 findings that the nurse should report to the provider immediately.
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Respiratory findings
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Bowel sounds
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Pupil findings
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Blood pressure
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Level of consciousness
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Heart rhythm
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Heart rate
Explanation
The Correct Answers are:
Respiratory findings
Pupil findings
Blood pressure
Level of consciousness
Heart rate
Explanation:
These findings indicate immediate concerns that could be life-threatening or require urgent medical intervention:
Respiratory findings (Shallow respirations, Respiratory rate 8/min)
Shallow respirations and a respiratory rate of 8/min are indicative of respiratory depression, which requires immediate attention as it could lead to respiratory failure.
Pupil findings (Constricted and sluggish pupils)
Constricted and sluggish pupils are often associated with opioid overdose or other central nervous system depressants. This requires immediate intervention to address potential toxicity.
Blood pressure (90/56 mm Hg)
The low blood pressure (hypotension) could be indicative of shock or inadequate circulation, requiring immediate attention to stabilize the client’s hemodynamic status.
Level of consciousness (Client does not respond to commands, grimaces to sternal rub)
A decreased level of consciousness or unresponsiveness, especially in the context of drug use, needs to be addressed immediately to assess for potential respiratory failure, drug toxicity, or neurological impairment.
Heart rate (56/min)
A heart rate of 56/min, though not dangerously low, could indicate bradycardia, especially in the context of opioid use, which can result in further complications if not addressed.
Why the other options are incorrect:
Bowel sounds (Hypoactive bowel sounds)
While hypoactive bowel sounds are a concern, they are less urgent compared to the other findings. They may be related to the client’s condition but do not require immediate intervention unless there is evidence of bowel obstruction or perforation, which is not indicated here
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