ATI RN
ATI Mental Health
1. A client with bipolar disorder is experiencing a manic episode. Which intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Monitor the client closely for signs of exhaustion.
- C. Encourage the client to rest and sleep as needed.
- D. Encourage the client to engage in regular physical activity.
Correct answer: A
Rationale: During a manic episode in bipolar disorder, individuals may exhibit increased energy levels, impulsivity, and reduced need for sleep, which can lead to risky behaviors and accidents. Providing a structured environment with minimal stimuli helps to reduce the risk of overstimulation and impulsive actions, thereby promoting the client's safety. This intervention aims to create a calm and controlled setting that can prevent potential harm to the client during this phase of the disorder.
2. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?
- A. Decrease the heparin rate.
- B. Increase the heparin rate.
- C. No change to the heparin rate.
- D. Stop the heparin; start warfarin (Coumadin).
Correct answer: B
Rationale: For clients on heparin therapy, a PTT value of 1.5 to 2.5 times the normal range is required to ensure therapeutic anticoagulation. The normal PTT range is 25 to 35 seconds. In this case, the client's PTT of 25 seconds falls below the therapeutic range, indicating that the heparin dose is insufficient. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired therapeutic effect.
3. A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse’s priority discharge intervention?
- A. Teaching adherence to an exercise program
- B. Teaching about a healthy dietary intake
- C. Teaching adherence to the antibiotic regimen
- D. Scheduling daily dressing changes
Correct answer: C
Rationale: The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.
4. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct answer: A
Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.
5. What is one of the best nutritional actions a caregiver can take to help a patient with Alzheimer's disease maintain appropriate body weight?
- A. Thicken liquids to prevent choking
- B. Supervise food planning and mealtimes
- C. Assist the person in completing a grocery checklist
- D. Feed the person their meals and snacks
Correct answer: B: Supervise food planning and mealtimes
Rationale: The correct answer is B, 'Supervise food planning and mealtimes'. This action ensures the patient with Alzheimer's disease maintains an appropriate diet and body weight, thus reducing the risk of malnutrition. While choices A, 'Thicken liquids to prevent choking', C, 'Assist the person in completing a grocery checklist', and D, 'Feed the person their meals and snacks', might be beneficial in certain circumstances, they do not directly contribute to the maintenance of appropriate body weight as effectively as supervising food planning and mealtimes does.
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