ATI mental health exam [QUESTIONS AND ANSWERS] EXAM DETAILED AND VERIFIED FOR
GUARANTEED PASS UPDATE GRADED A (BRAND NEW!!)
Question Options Answer Rationale
a. Administer
kayexalate
b. Place the client
A client with chronic kidney Hyperkalemia can cause life-
on a cardiac
disease has a serum threatening cardiac
monitor
potassium level of 6.5 mEq/L. b arrhythmias. Continuous
c. Encourage a
Which action should the cardiac monitoring is the
high-potassium
nurse take first? immediate priority.
diet
d. Notify the
provider
a. Increase the
oxygen flow to 4
A client with pneumonia is L/min
Confusion and restlessness
prescribed oxygen via nasal b. Check the
may indicate hypoxia.
cannula at 2 L/min. The client client’s oxygen
b Assessing oxygen saturation is
becomes confused and saturation
the first step before
restless. What should the c. Call the provider
interventions.
nurse do first? immediately
d. Reposition the
client upright
a. Administer
acetaminophen
and monitor
A post-op client develops a b. Encourage oral
Early post-op fever may
temperature of 38.5°C fluids and
indicate infection. Assessing
(101.3°F) on the second day ambulate
d the surgical site helps identify
after surgery. What is the c. Notify the
potential sources before
most appropriate nursing provider
further interventions.
action? immediately
d. Check the
surgical site for
signs of infection
A client with heart failure a. Instruct the b Rapid weight gain suggests
reports sudden weight gain client to restrict fluid retention. Assessing
,Question Options Answer Rationale
of 3 kg in 2 days. What fluids edema and lung sounds is
should the nurse do first? b. Assess for essential to determine severity
edema and before interventions.
respiratory status
c. Notify the
provider
d. Administer a
diuretic
a. Slow the
transfusion rate
A client receiving a blood b. Stop the These are signs of a hemolytic
transfusion reports chills and transfusion and transfusion reaction. The
back pain 10 minutes after notify the provider b transfusion must be stopped
starting. What is the first c. Administer immediately to prevent
action? acetaminophen complications.
d. Monitor vital
signs
a. Supine with legs
elevated
A client with COPD is High-Fowler’s position
b. High-Fowler’s
experiencing shortness of maximizes lung expansion and
position b
breath and wheezing. Which facilitates breathing in clients
c. Prone position
position is most appropriate? with respiratory distress.
d. Trendelenburg
position
a. Administer oral
insulin
A client with type 2 diabetes These are signs of
b. Obtain a blood
presents with fruity breath, hyperglycemic crisis (DKA).
glucose level
nausea, and confusion. b Confirming blood glucose is
c. Encourage oral
Which intervention is the the first step to guide urgent
fluids
nurse’s priority? treatment.
d. Notify the
provider
a. Milk the chest Sudden dyspnea and
A client with a chest tube
tube b decreased drainage may
reports sudden onset of
b. Check for kinks indicate tube obstruction.
dyspnea and decreased
or obstruction Checking for kinks ensures
, Question Options Answer Rationale
drainage. What should the c. Clamp the chest proper functioning before
nurse do first? tube notifying the provider.
d. Notify the
provider
a. Apply a warm
compress
b. Measure calf These are signs of deep vein
A post-op client is
circumference thrombosis. The provider must
experiencing calf pain and
c. Elevate the leg d be notified immediately;
swelling in one leg. What is
and encourage interventions like ambulation
the priority nursing action?
ambulation could dislodge a clot.
d. Notify the
provider
a. Encourage oral
intake
A client with acute b. Assess vital signs Assessing vital signs and pain
pancreatitis has severe and pain helps determine the severity
abdominal pain, vomiting, c. Administer b and urgency of the client’s
and low-grade fever. What pancreatic condition, guiding immediate
should the nurse do first? enzymes interventions.
d. Position the
client supine
Question:
A nurse is planning overall strategies to address problems for a client who has borderline
personality disorder. Which of the following strategies is the priority for the nurse to
incorporate into the plan of care?
a. Discuss the appropriate use of assertive behavior with the client
b. Encourage the client to attend weekly support group meetings
c. Assist the client to maintain awareness of her thoughts and feelings
d. Implement measures to prevent intentional self-inflicted injury
Answer: d. Implement measures to prevent intentional self-inflicted injury
Rationale: Safety is always the priority in clients with borderline personality disorder due
to the high risk of self-harm. Once safety is ensured, other therapeutic interventions can
be implemented.
GUARANTEED PASS UPDATE GRADED A (BRAND NEW!!)
Question Options Answer Rationale
a. Administer
kayexalate
b. Place the client
A client with chronic kidney Hyperkalemia can cause life-
on a cardiac
disease has a serum threatening cardiac
monitor
potassium level of 6.5 mEq/L. b arrhythmias. Continuous
c. Encourage a
Which action should the cardiac monitoring is the
high-potassium
nurse take first? immediate priority.
diet
d. Notify the
provider
a. Increase the
oxygen flow to 4
A client with pneumonia is L/min
Confusion and restlessness
prescribed oxygen via nasal b. Check the
may indicate hypoxia.
cannula at 2 L/min. The client client’s oxygen
b Assessing oxygen saturation is
becomes confused and saturation
the first step before
restless. What should the c. Call the provider
interventions.
nurse do first? immediately
d. Reposition the
client upright
a. Administer
acetaminophen
and monitor
A post-op client develops a b. Encourage oral
Early post-op fever may
temperature of 38.5°C fluids and
indicate infection. Assessing
(101.3°F) on the second day ambulate
d the surgical site helps identify
after surgery. What is the c. Notify the
potential sources before
most appropriate nursing provider
further interventions.
action? immediately
d. Check the
surgical site for
signs of infection
A client with heart failure a. Instruct the b Rapid weight gain suggests
reports sudden weight gain client to restrict fluid retention. Assessing
,Question Options Answer Rationale
of 3 kg in 2 days. What fluids edema and lung sounds is
should the nurse do first? b. Assess for essential to determine severity
edema and before interventions.
respiratory status
c. Notify the
provider
d. Administer a
diuretic
a. Slow the
transfusion rate
A client receiving a blood b. Stop the These are signs of a hemolytic
transfusion reports chills and transfusion and transfusion reaction. The
back pain 10 minutes after notify the provider b transfusion must be stopped
starting. What is the first c. Administer immediately to prevent
action? acetaminophen complications.
d. Monitor vital
signs
a. Supine with legs
elevated
A client with COPD is High-Fowler’s position
b. High-Fowler’s
experiencing shortness of maximizes lung expansion and
position b
breath and wheezing. Which facilitates breathing in clients
c. Prone position
position is most appropriate? with respiratory distress.
d. Trendelenburg
position
a. Administer oral
insulin
A client with type 2 diabetes These are signs of
b. Obtain a blood
presents with fruity breath, hyperglycemic crisis (DKA).
glucose level
nausea, and confusion. b Confirming blood glucose is
c. Encourage oral
Which intervention is the the first step to guide urgent
fluids
nurse’s priority? treatment.
d. Notify the
provider
a. Milk the chest Sudden dyspnea and
A client with a chest tube
tube b decreased drainage may
reports sudden onset of
b. Check for kinks indicate tube obstruction.
dyspnea and decreased
or obstruction Checking for kinks ensures
, Question Options Answer Rationale
drainage. What should the c. Clamp the chest proper functioning before
nurse do first? tube notifying the provider.
d. Notify the
provider
a. Apply a warm
compress
b. Measure calf These are signs of deep vein
A post-op client is
circumference thrombosis. The provider must
experiencing calf pain and
c. Elevate the leg d be notified immediately;
swelling in one leg. What is
and encourage interventions like ambulation
the priority nursing action?
ambulation could dislodge a clot.
d. Notify the
provider
a. Encourage oral
intake
A client with acute b. Assess vital signs Assessing vital signs and pain
pancreatitis has severe and pain helps determine the severity
abdominal pain, vomiting, c. Administer b and urgency of the client’s
and low-grade fever. What pancreatic condition, guiding immediate
should the nurse do first? enzymes interventions.
d. Position the
client supine
Question:
A nurse is planning overall strategies to address problems for a client who has borderline
personality disorder. Which of the following strategies is the priority for the nurse to
incorporate into the plan of care?
a. Discuss the appropriate use of assertive behavior with the client
b. Encourage the client to attend weekly support group meetings
c. Assist the client to maintain awareness of her thoughts and feelings
d. Implement measures to prevent intentional self-inflicted injury
Answer: d. Implement measures to prevent intentional self-inflicted injury
Rationale: Safety is always the priority in clients with borderline personality disorder due
to the high risk of self-harm. Once safety is ensured, other therapeutic interventions can
be implemented.
