ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 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 2 of 5
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, 'I'm feeling sad. I don't want to talk now.' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: It will help you feel better if you talk about it.' While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress. 'Come on out and get involved with the game the other clients are playing.' Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate. 'I'll stay with you for a few minutes.' This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability. 'I'll come back when you feel like talking.' This response leaves the client alone, which may be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.
Question 3 of 5
A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale: You may experience muscle cramping from the induced seizure.' While muscle stiffness is possible, the term 'muscle cramping' might not accurately describe the postictal state after ECT. 'The most common adverse effects of ECT are related to anesthesia.' While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache. 'You should expect to have ECT once per week for 6 weeks.' The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients. 'You might feel a bit confused and disoriented when you first wake up.' This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.
Question 4 of 5
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse Include?
Correct Answer: C
Rationale: Avoid foods that contain tyramine' is not relevant to fluoxetine. Tyramine restriction is a concern with certain medications, such as monoamine oxidase inhibitors (MAOIs), but not with SSRIs like fluoxetine. 'Plan to discontinue this medication as soon as your depression is relieved' is not advisable. Discontinuing an antidepressant abruptly can lead to withdrawal symptoms and may not allow for the full resolution of depressive symptoms. The decision to discontinue medication should be made in consultation with a healthcare provider. 'Expect that your mood might take one to three weeks to begin improving' is a crucial piece of information to provide because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), often takes a few weeks to start exerting its therapeutic effects. It's important for the client to understand that the full benefits of the medication may not be felt immediately. 'Stop taking this medication if weight loss or gain occurs' is not an appropriate instruction. Weight changes are potential side effects of fluoxetine, but the decision to continue or discontinue the medication should be based on consultation with a healthcare provider. Abruptly stopping medication without medical guidance can lead to withdrawal symptoms and is not recommended.
Question 5 of 5
A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Constantly talking about the traumatic experience is a symptom of intrusive thoughts and re-experiencing, which is characteristic of PTSD. The client is easily startled by loud voices. Individuals with PTSD often experience heightened arousal and increased reactivity to stimuli. Being easily startled by loud voices is a common symptom of hypervigilance and increased arousal seen in PTSD. Reporting satisfying personal relationships with family and close friends is less likely in individuals with PTSD. PTSD can negatively impact interpersonal relationships due to symptoms such as emotional numbing, avoidance, and hypervigilance. Constant drowsiness and sleeping 11-12 hours daily are not typical findings in PTSD. Individuals with PTSD may experience sleep disturbances, such as insomnia, nightmares, or hyperarousal-related sleep problems.