ATI LPN
LPN Custom Mental Health Questions
Extract:
Graphic Record 0800: Blood pressure 118/76 mm Hg, Temperature 36.9°C (98.4°F), Heart rate 88/min, Respiratory rate 18/min. 1300: Blood pressure 116/74 mm Hg, Temperature 37.7°C (99.9°F), Heart rate 96/min, Respiratory rate 16/min
Question 1 of 5
. A nurse is assisting with the care for a newly admitted client who has major depressive disorder. Select 1 condition and 1 client finding to fill in the following sentence (Separate using a comma). The client is at risk for developing ___ due to the Client's intake of ___
Correct Answer: C,B
Rationale: The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort. St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body. In the given scenario, the nurse should identify: Condition: The client's intake of St. John's wort; Client Finding: At risk for developing serotonin syndrome. This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.
Extract:
Question 2 of 5
A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
Correct Answer: A
Rationale: The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended. Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm. Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others. Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or others.
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 preparing to administer haloperidol 5 mg IM to a client. Available is haloperidol 50 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.1
Rationale:
To calculate the amount of haloperidol (in mL) that the nurse should administer, use the following formula: Volume (mL) = Dose (mg) / Concentration (mg/mL). In this case: Volume (mL) = 5 mg / 50 mg/mL = 0.1 mL.
Therefore, the nurse should administer 0.1 mL of haloperidol.
Question 5 of 5
A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently. Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.