ATI LPN
ATI LPN Mental Health Level 4 Exam Questions
Extract:
Question 1 of 5
A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
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.
Question 2 of 5
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
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.
Question 3 of 5
A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: The correct answer, indicated as 2.
Rationale: The nurse needs to administer 1 mg of clonazepam, and since each tablet is 0.5 mg, the nurse should give 2 tablets to provide the correct dose. Calculation: 1 mg / 0.5 mg per tablet = 2 tablets.
Question 4 of 5
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
Correct Answer: B
Rationale: The correct answer, indicated as B.
Rationale: Telling parents not to talk about the attempt may reflect withdrawal or denial but does not necessarily indicate ongoing suicidal intent. Giving away personal possessions, such as a CD collection, is a common behavior in adolescents with suicidal intent, as they may believe they won't need these items in the future. Wanting to spend more time with peers than parents could indicate normal adolescent development, rather than a sign of suicidal intent. Preferring to eat meals while watching TV is not a concerning behavior in the context of suicide risk.
Question 5 of 5
A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer, indicated as D.
Rationale: Telling the client to 'work hard' to stay on schedule does not address the underlying difficulty with medication adherence. Saying not to worry about past issues may minimize the client's concerns and challenges. Asking 'why' the client finds it difficult to take medications might not encourage open communication and could make the client feel judged. Collaborating with the client to create a schedule that is convenient and achievable increases the likelihood of adherence and fosters a sense of control and partnership.