ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 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 2 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 3 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.
Question 4 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 5 of 5
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?
Correct Answer: A
Rationale: Potassium 2.8 mEq/L. Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention. Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia. Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent. Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.