a psychiatric nurse is reviewing prescriptions for a patient with major depression at the county clinic since the patient has a mild intellectual disa a psychiatric nurse is reviewing prescriptions for a patient with major depression at the county clinic since the patient has a mild intellectual disa
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2023

1. A nurse is reviewing prescriptions for a patient with major depression at the county clinic. Since the patient has a mild intellectual disability, the nurse would question which classification of antidepressant drugs:

Correct answer: B

Rationale: Monoamine oxidase inhibitors are less suitable for patients with intellectual disabilities due to the need for dietary restrictions and close monitoring. These restrictions can be challenging for patients with mild intellectual disabilities to follow, making this drug class a concern for this patient population.

2. The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?

Correct answer: A

Rationale: When administering an IV bolus of heparin, the most important nursing action is to monitor the client's heart rate. Heparin can cause bradycardia as a side effect, making it crucial to assess the heart rate for any abnormalities. Checking the blood pressure (Choice B) is important but not as critical as monitoring the heart rate. While checking for signs of bleeding (Choice C) is essential, it is not the most crucial action when administering heparin. Monitoring the respiratory rate (Choice D) is also important but not as directly related to the potential side effects of heparin as monitoring the heart rate.

3. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?

Correct answer: Confront the client about this behavior.

Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.

4. A healthcare professional is planning to administer subcutaneous enoxaparin 40 mg using a prefilled syringe of Enoxaparin 40 mg/0.4 mL to an adult client following hip arthroplasty. Which of the following actions should the healthcare professional plan to take?

Correct answer: B

Rationale: Correct Answer: B. When administering enoxaparin, it is essential to insert the needle completely into the client's tissue to ensure a deep subcutaneous injection. This method helps in the appropriate delivery of the medication. Choice A is incorrect because expelling air bubbles is not necessary with subcutaneous injections and may lead to medication loss. Choice C is incorrect as enoxaparin is usually administered in the abdomen, not the thigh. Choice D is incorrect as aspiration is not recommended for subcutaneous injections to avoid trauma or bleeding.

5. A healthcare professional is assessing a client who is 24 hours postoperative following an open cholecystectomy. Which of the following findings should the healthcare professional report to the provider?

Correct answer: D

Rationale: A WBC count of 15,000/mm³ is elevated and may indicate infection, which should be reported. High WBC count is a sign of inflammation or infection, and in a postoperative client, it can be indicative of surgical site infection or another complication. Urinary output, serosanguineous wound drainage, and a heart rate of 94/min are all within normal ranges for a client post cholecystectomy and do not raise immediate concerns for infection or complications.

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