ATI RN
ATI Mental Health Practice B
1. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?
- A. Encourage the client to express feelings about the suicide attempt.
- B. Place the client on one-to-one observation.
- C. Discuss the client's feelings about the suicide attempt.
- D. Encourage the client to participate in group therapy.
Correct answer: B
Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.
2. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
- A. Apply a cold compress
- B. Discontinue the IV line
- C. Elevate the limb
- D. Increase the IV flow rate
Correct answer: B
Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.
3. A client is starting a new prescription for enalapril. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Rise slowly from a sitting position.
- C. Avoid salt substitutes.
- D. Avoid exposure to sunlight.
Correct answer: C
Rationale: The correct instruction for a client starting enalapril is to avoid salt substitutes. Salt substitutes may contain potassium, which could lead to elevated potassium levels when combined with enalapril, increasing the risk of hyperkalemia. Choices A, B, and D are incorrect because there is no specific need to take enalapril with food, rise slowly from a sitting position, or avoid exposure to sunlight when taking this medication.
4. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?
- A. Heart rate of 90/min
- B. Blood pressure of 118/76 mm Hg
- C. Warmth and redness in the calf
- D. Pink-tinged urine
Correct answer: C
Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.
5. A client with breast cancer is receiving cyclophosphamide. Which of the following findings should the nurse monitor?
- A. Hypertension
- B. Hyperglycemia
- C. Ototoxicity
- D. Hemorrhagic cystitis
Correct answer: D
Rationale: The nurse should monitor the client for hemorrhagic cystitis when receiving cyclophosphamide due to its potential to cause bladder irritation and lead to this serious adverse effect. It is essential to assess for symptoms such as hematuria, dysuria, and flank pain. Monitoring for hypertension, hyperglycemia, and ototoxicity is not directly related to the side effects of cyclophosphamide.
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