ATI LPN
ATI LPN Mental Health Level 4 test II Questions
Question 1 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.
Question 2 of 5
A nurse is caring for an adolescent who has experienced abuse and neglect since early childhood. The nurse should understand that this is an example of which of the following types of trauma?
Correct Answer: B
Rationale: Histrionic trauma: This term is not used in trauma classification. Chronic trauma: Chronic trauma refers to repeated and prolonged exposure to traumatic events, such as ongoing abuse or neglect over a long period. Vicarious trauma: This occurs when someone experiences trauma indirectly, such as through exposure to another person's trauma. Acute trauma: Acute trauma results from a single, isolated event rather than repeated occurrences.
Question 3 of 5
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions is the nurse's priority?
Correct Answer: D
Rationale: Offer the client high-calorie fluids: This is not a priority during a panic attack. Addressing physical needs comes later. Administer an antianxiety medication to the client: Medication may be part of treatment but is not the immediate priority. Teach the client relaxation exercises: Relaxation exercises are valuable but should be introduced after the acute phase of the panic attack has passed. Remain with the client in a quiet area. Remaining with the client provides reassurance, safety, and emotional support, which are critical during a panic attack.
Extract:
Nurse Notes
Client: Doug Smith
Patient presents with symptoms of anxiety escalated to a panic attack. Patient reports chest pain, tingling in fingers, and difficulty breathing, with a sense of impending doom. Patient appears anxious and distressed, with rapid shallow breathing. SPO2 levels initially low due to hyperventilation. Provided reassurance to the patient and explained that symptoms are related to a panic attack, not a heart attack.
Vital signs
• Temperature: 36.7°C (98.1°F)
• Heart rate: 110 bpm
• Respiratory rate: 28 breaths/min
• Blood pressure: 140/90 mmHg
• Oxygen saturation: 94% on room air (increased to 98% with 2L O2 via nasal cannula)
EKG
Normal sinus rhythm. Mild tachycardia noted.
Provider orders
02 @ 2L keep SPO2 > 92%
ABGS
CBC, BMP
UA with reflex
Psych evaluation and treat
0.5 mg IVP Ativan- One-time order give now
No Caffeine, limit processed foods and sugar/carbs in diet
Question 4 of 5
Doug has been seen in the ER for his anxiety that has escalated to a panic attack. He thought he was dying because his symptoms were very similar to a heart attack with tingling in his fingers, pain in his chest, and difficulty breathing. He was even starting to feel out of sorts due to his lack of oxygen related to his low SPO2 levels related to his hyperventilation. In class we discussed it being caused by respiratory alkalosis. In the left column there are items that will require follow up by either the nurse or Doug to maintain a successful plan of care upon discharge. If they are for the nurse she must educate Doug, if they are for Doug, he must comply with the plan...either way if they require follow up, place a check in the FOLLOW UP Column, if they don't place a check in the N/A Column. Each item will have one check in one of the columns.
| Options | Follow Up | N/A |
|---|---|---|
| Controlling son's success | ||
| Focus on the Positives | ||
| Better Relationship with Son | ||
| Techniques to Manage Stress | ||
| Energy Drinks | ||
| Conflict Resolution |
Correct Answer: B,C,D,E,F
Rationale: A (N/
A) Controlling son's success: This does not directly relate to Doug's health or anxiety management plan, so it falls under N/A. Focus on the positives: Encouraging positive thinking can improve Doug's coping skills, making it a follow-up item. Better relationship with son: Addressing family dynamics can improve Doug's overall mental health, requiring follow-up. Techniques to manage stress: Essential for managing anxiety and preventing future panic attacks, requiring follow-up. Energy drinks: Caffeine can exacerbate anxiety symptoms, making this a follow-up item. Conflict resolution: Managing interpersonal conflict is key to reducing stress, requiring follow-up.
Extract:
Question 5 of 5
A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
Correct Answer: C
Rationale: Incoherent speech: This is a symptom of severe or panic-level anxiety, not mild anxiety. Chest pain: This is associated with more severe anxiety, particularly panic attacks. Irritability: Mild anxiety can cause irritability and heightened awareness of surroundings, which may manifest as restlessness or slight tension. Insomnia: While it can occur with anxiety, it is more commonly linked to moderate or severe levels.