ATI LPN
ATI LPN Mental Health Level 4 test II Questions
Question 1 of 5
A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?
Correct Answer: A
Rationale: Assess for risk of immediate harm to patient or children: The priority is to ensure the immediate safety of the client and any children involved. If there is a risk of harm, emergency services or protective measures must be initiated. Implement the safety plan: Implementing the safety plan is important but secondary to assessing the immediate risk. Without first understanding the level of danger, the safety plan might not address urgent needs. Refer the client to a community support group: This is a valuable intervention for long-term support but is not the priority in an acute situation where immediate risk must be assessed. Instruct the client on how to leave the relationship: While planning for leaving the relationship is critical, it is not the immediate priority, especially if the client or children are in danger.
Question 2 of 5
A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?
Correct Answer: B
Rationale: This medication can cause a dry cough.': A dry cough is not a common side effect of sertraline. 'I should call the provider if I experience excessive sweating and muscle twitching.' Excessive sweating and muscle twitching could indicate serotonin syndrome, a potentially life-threatening condition associated with SSRIs like sertraline. Early recognition and prompt intervention are crucial. 'This medication can cause harmless, temporary changes to my ability to taste and smell.': Changes in taste or smell are not typical side effects of sertraline. This statement is incorrect and does not reflect the drug's known side effect profile. 'I need to decrease my sodium intake while on this medication.': Sodium intake is not typically affected by sertraline use. However, sertraline can cause hyponatremia in some cases, especially in older adults.
Question 3 of 5
A nurse working at a middle school suspects that a student is experiencing physical abuse after collecting data from the student. Which of the following actions should the nurse take next?
Correct Answer: A
Rationale: Make a report to Child Protective Services (CPS). Nurses are mandated reporters and must report suspected abuse to the appropriate authorities, such as CPS, to ensure the safety of the child. Call the police and report the suspected abuse: While police involvement may be necessary, CPS is the primary agency for child welfare and abuse cases. Alert the school office to call parents: Informing the parents could place the child at further risk if the parents are the perpetrators. Call the child's guardian to have the child's pediatrician confirm the suspected abuse: This delays reporting and does not ensure immediate intervention to protect the child.
Question 4 of 5
A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?
Correct Answer: B
Rationale: Provide the client with strategies for interacting with others in social situations: This is not directly related to addressing intimate partner violence and does not prioritize safety or support. Provide the client with information on resources in the community to support victims of violence. Offering resources empowers clients to make informed decisions and provides them with the support they may need to address their situation. Tell the client ways to avoid making their partner angry to prevent intimate partner violence: This response implies victim-blaming and is inappropriate. The responsibility for violence lies with the perpetrator, not the victim. The nurse instructs the client on ways to behave to prevent making their partner angry: Like the previous option, this implies victim-blaming and is not supportive or empowering for the client.
Question 5 of 5
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?
Correct Answer: B
Rationale: Use negative reinforcement techniques to prevent the client from performing rituals: Negative reinforcement is not a therapeutic or evidence-based approach for managing OCD. Determine the client's level of anxiety: Anxiety levels often influence compulsive behaviors. Assessing the client's anxiety helps guide interventions to manage it effectively. Encourage avoidance of situations that increase anxiety: Avoidance reinforces the OCD cycle and is not a constructive coping strategy. Interrupt the compulsive behavior: Abruptly interrupting rituals can increase the client's anxiety and distress.