ATI RN
ATI Mental Health Proctored Exam 2019
1. A client has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?
- A. Feelings of detachment from one's body
- B. Fear of gaining weight
- C. Paralysis of a limb
- D. Episodes of hypomania
Correct answer: A
Rationale: Depersonalization/derealization disorder is characterized by feelings of detachment from one's body or surroundings. Individuals with this disorder may feel like they are observing themselves from outside their body or that the world around them is unreal. Therefore, the nurse should expect behaviors such as feelings of detachment from one's body (A). Fear of gaining weight (B) is more indicative of an eating disorder, paralysis of a limb (C) could be related to neurological issues, and episodes of hypomania (D) are associated with mood disorders like bipolar disorder, but not specifically with depersonalization/derealization disorder.
2. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?
- A. Lying supine with the legs straight
- B. Massaging the abdomen
- C. Using antispasmodic medication
- D. Using relaxation techniques
Correct answer: A
Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.
3. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?
- A. Heat only 10 oz or more.
- B. Do not thaw or heat breast milk in a microwave oven.
- C. Always leave the bottle top uncovered to allow heat to escape.
- D. Shake the bottle vigorously for at least 30 seconds after heating.
Correct answer: B
Rationale: Thawing or heating breast milk in a microwave is not recommended because it can create hot spots that may burn the infant and destroy essential nutrients.
4. Which of the following procedures always requires surgical asepsis?
- A. Vaginal instillation of conjugated estrogen
- B. Urinary catheterization
- C. Nasogastric tube insertion
- D. Colostomy irrigation
Correct answer: B
Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.
5. Which of the following substances is involved in the destruction of ingested pathogens?
- A. lymphatic fluid
- B. stomach acid
- C. bicarbonate
- D. lipase
Correct answer: stomach acid
Rationale: The correct answer is stomach acid. Stomach acid, also known as gastric acid, plays a crucial role in destroying ingested pathogens due to its high acidity. The low pH of stomach acid helps to kill bacteria and other pathogens that may be present in the food we consume. Lymphatic fluid is involved in immune function and fat absorption, not pathogen destruction. Bicarbonate is a base that neutralizes stomach acid to prevent damage to the stomach lining. Lipase is an enzyme that aids in the digestion of fats but is not involved in pathogen destruction.
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