ATI RN
ATI Mental Health Proctored Exam 2019
1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?
- A. Tell me more about these voices.
- B. Let's explore these voices together.
- C. How long have you been hearing these voices?
- D. Have you told anyone else about these voices?
Correct answer: A
Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.
2. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?
- A. To improve circulation and relieve pressure.
- B. To prevent contractures and muscle atrophy.
- C. To prevent skin breakdown and pressure ulcers.
- D. To improve respiratory function and prevent pneumonia.
Correct answer: C
Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.
3. A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?
- A. Increased urine output
- B. Bounding peripheral pulses
- C. Weight loss
- D. Decreased heart rate
Correct answer: B
Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.
4. Churns chyme and has an environment of pH2; holds 4-6 cups of food:
- A. stomach
- B. pancreas
- C. large intestine
- D. small intestine
Correct answer: A
Rationale: The stomach churns food into chyme and has a highly acidic environment (pH 2) to aid in the digestion of proteins and other nutrients.
5. What is the best dietary recommendation for a patient with chronic kidney disease?
- A. Low-protein diet
- B. High-protein diet
- C. Low-sodium diet
- D. High-sodium diet
Correct answer: C
Rationale: The correct answer is a low-sodium diet. Patients with chronic kidney disease are often advised to follow a low-sodium diet to help manage fluid retention. Excessive sodium intake can lead to fluid buildup in the body, causing complications for individuals with kidney issues. Choices A and B are incorrect because while protein intake may need to be monitored in kidney disease, the primary focus is typically on sodium restriction. Choice D is incorrect as a high-sodium diet would exacerbate fluid retention in patients with chronic kidney disease.
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