ATI LPN Mental Health Level 4 Exam | Nurselytic

Correct Answer: C

Rationale: The correct answer, indicated as C.
Rationale: Wrapping the blood pressure cuff snugly around the arm is correct, as the cuff needs to be secure to ensure an accurate reading. Centering the cuff bladder over the brachial artery is correct, as this is necessary for accurate blood pressure measurement. Placing the client's arm above the level of the heart is incorrect. The arm should be at heart level to ensure the accuracy of the reading. If the arm is elevated, it could result in a falsely low reading. Checking the instrument gauge to ensure the reading starts at zero is correct. This step is important to ensure the accuracy of the measurement.

Correct Answer: C

Rationale: The correct answer, indicated as C.
Rationale: A pulse deficit refers to a condition where there is a difference between the radial and apical pulse rates, not a phenomenon heard during blood pressure measurement. Diastolic pressure is the point at which sounds fade away or become muffled, but the silence between sounds refers to a different concept, not the actual diastolic pressure. An auscultatory gap is the term used to describe a silent interval between the systolic and diastolic sounds during blood pressure measurement. This can lead to inaccurately low readings if not identified. A widened pulse pressure refers to a larger-than-normal difference between systolic and diastolic pressure, which is not related to the auscultatory silence.

Correct Answer: A

Rationale: The correct answer, indicated as A.
Rationale: Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another. While checking medications is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min).
Therefore, notifying the doctor of bradycardia is not appropriate in this case.

Correct Answer: D

Rationale: The correct answer, indicated as D.
Rationale: People with histrionic personality disorder do not have difficulty identifying with the feelings of others; instead, they seek attention through dramatic or exaggerated behavior. A person with histrionic personality disorder does not typically view themselves as inferior. They tend to overvalue their attractiveness and seek admiration. Manipulating others for personal gain is more characteristic of narcissistic personality disorder, not histrionic personality disorder. Clients with histrionic personality disorder often use physical appearance and behavior to draw attention to themselves. This is a key characteristic of the disorder.

Correct Answer: B

Rationale: The correct answer, indicated as B.
Rationale: Hostility and sarcasm are concerning, but they are not as urgent as the risk of injury associated with hyperactivity. Pacing in the hallway during the day and night is indicative of extreme restlessness and may lead to exhaustion or self-harm. The nurse should address this behavior to prevent harm. Giving money away may be problematic, but it is a less immediate risk compared to physical safety. Flight of ideas is a common symptom of mania, but it is less dangerous than pacing and hyperactivity, which can lead to physical harm.