ATI LPN
LPN Custom Mental Health Questions
Question 1 of 5
As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. 'Why don't you shut up already! I can read it myself, you know!' Which of the following is an appropriate nursing response?
Correct Answer: C
Rationale: I know you can read it yourself, but will you?' This response may escalate the situation and may not effectively address the inappropriate tone. It also has the potential to be perceived as confrontational. 'We do this every day. Why are you so angry with me this morning?' This response is somewhat confrontational and may not be as effective in setting clear boundaries. It also focuses on the client's emotion without directly addressing the inappropriate tone. 'I expect you to speak to me in a civil tone of voice.' Option C sets clear boundaries and communicates the expectation of respectful communication. Addressing the inappropriate tone of voice is important in working with individuals with borderline personality disorder. It reinforces the importance of maintaining a therapeutic and respectful interaction. 'Fine. Here is the schedule. I expect you to be on time for your therapy sessions.' While this response provides the information, it doesn't address the issue of the client's disrespectful tone. It's important to address the inappropriate behavior while still providing necessary information.
Question 2 of 5
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?
Correct Answer: C
Rationale: Planning with the client for how he can better handle frustration (option
A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time. Placing the client in a monitored seclusion room until he is calm (option
B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps. Offer the client an antianxiety medication. When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented. Restraining the client to prevent injury to himself or others (option
D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.
Question 3 of 5
A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics. Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking. Directly challenging the delusions can increase defensiveness and mistrust. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.
Question 4 of 5
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?
Correct Answer: A
Rationale: I should sit on the side of the bed before standing up in the morning.' Amitriptyline is a tricyclic antidepressant that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing.
To minimize the risk of dizziness or fainting, clients taking amitriptyline should be advised to sit on the side of the bed for a few moments before standing up, especially in the morning when orthostatic changes may be more pronounced. 'I may experience an increased libido.' This statement is not related to the common side effects of amitriptyline. Changes in libido are not typically associated with this medication. 'I will avoid drinking caffeinated beverages.' While it's generally a good idea to limit caffeine intake, this statement is not a specific instruction related to amitriptyline. However, reducing caffeine consumption can be beneficial because amitriptyline may enhance the stimulant effects of caffeine. 'I can no longer eat pepperoni pizza.' This statement is not directly related to amitriptyline. There are no specific dietary restrictions associated with amitriptyline use, and the client can continue to eat pepperoni pizza unless there are individual dietary concerns or interactions with other medications.
Question 5 of 5
A nurse is talking with a client who has schizophrenia. Suddenly the client states, 'I'm frightened. Do you hear that? The voices are telling me to do terrible things.' Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: Why do you think you are hearing the voices?' This question may come across as confrontational and might make the client defensive. It's better to focus on the content of the hallucinations rather than questioning the client's perception. 'What are the voices telling you to do?' This response is appropriate because it acknowledges the client's experience, shows empathy, and encourages the client to express their thoughts and feelings. It is important to gather more information about the content of the hallucinations and delusions to understand the client's perception of reality. 'You need to tell the voices to leave you alone.' This response oversimplifies the experience of hallucinations and may not be helpful. Telling the client to dismiss the voices is unlikely to be effective and may lead to frustration. 'You need to understand that there are no voices.' Denying the client's experience is not therapeutic. It's essential to validate the client's feelings and explore their subjective experience rather than dismissing it outright.