ATI RN
ATI Mental Health Practice B
1. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client to describe the content of the hallucinations.
- B. Instruct the client to ignore the hallucinations.
- C. Administer prescribed antipsychotic medication.
- D. Engage the client in reality-based activities.
Correct answer: A
Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.
2. A healthcare provider is providing a report to a colleague about a client who weighs 210 lb and has a prescription for one-third weight bearing on the right leg. How many kg of weight should the client bear on the right leg?
- A. 32 kg
- B. 35 kg
- C. 40 kg
- D. 45 kg
Correct answer: A
Rationale: To calculate the weight-bearing limit, we first need to convert 210 lbs to kg. To do this, we use the conversion factor 1 lb = 0.453592 kg. So, 210 lbs is equal to 210 * 0.453592 = 95.254 kg. One-third of 95.254 kg is 31.7513 kg, which can be rounded to 32 kg. Therefore, the client should bear 32 kg of weight on the right leg. Choice A is the correct answer. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the client's weight and the prescribed weight-bearing limit.
3. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?
- A. Notify the doctor immediately.
- B. Stop the feeding, and clamp the NG tube.
- C. Discard the 220ml, and clamp the NG tube.
- D. Give a prescribed GI stimulant such as metoclopramide (Reglan).
Correct answer: B
Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.
4. What name is given to inflammation of the bladder?
- A. Cystitis
- B. Urethritis
- C. Urosepsis
- D. Bacteriuria
Correct answer: A
Rationale: Cystitis is the medical term for inflammation of the bladder. Urethritis refers to inflammation of the urethra, urosepsis to a systemic infection stemming from the urinary tract, and bacteriuria to the presence of bacteria in the urine.
5. A nurse is caring for a client after knee replacement surgery. The nurse discovers that the consent was not signed before the surgery. Which of the following charges could be filed?
- A. False imprisonment
- B. Libel
- C. Battery
- D. Malpractice
Correct answer: C
Rationale: The correct answer is C: Battery. Battery occurs when an individual is touched without consent. Performing surgery without a signed consent constitutes battery as it involves touching the patient's body without proper authorization. False imprisonment (choice A) involves restraining someone against their will, which is not applicable in this scenario. Libel (choice B) refers to written defamation, which is not relevant to the situation described. Malpractice (choice D) involves negligence or incompetence in providing professional services, which is different from the lack of consent issue presented in this case.
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