ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 of 5
A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa. Physical Examination: Client appears preoccupied and displays poor concentration but is oriented X3. Client has very thin appearance, measuring 5 feet 2 inches tall and weighing 42.6 kg (94 lb). This calculates to 81% of ideal target weight. Client skin color is pallor with capillary refill greater than 2 seconds. When asked about fainting, client minimizes it and comments, 'I was just tired. it was nothing.' Which of the following 5 findings require immediate follow-up by the nurse?
Correct Answer: A,B,D
Rationale: A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa. B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent. D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention. E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances. F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first. G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.
Question 2 of 5
A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?
Correct Answer: A
Rationale: Uncontrolled movements around the mouth. Tardive dyskinesia is a side effect associated with the long-term use of antipsychotic medications, especially first-generation or typical antipsychotics. It is characterized by involuntary, repetitive movements, often involving the face, such as uncontrolled movements around the mouth (e.g., lip smacking, puckering, chewing). Seizures and tremors are not typical adverse effects of tardive dyskinesia. They are more commonly associated with other side effects or conditions. Nausea and vomiting are not typically associated with tardive dyskinesia. These symptoms may be side effects of antipsychotic medications, but they are not characteristic of tardive dyskinesia itself. Hallucinations and delusions are not associated with tardive dyskinesia. Tardive dyskinesia primarily involves involuntary movements and is not related to changes in thought content or perception.
Question 3 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.
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.
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 5 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.