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. Nurses' Notes: Client brought to the ED by parent due to a fainting at home earlier this evening. Parent reports that client has been worried about their weight and been refusing to eat. Parent also reports client has been spending several hours at the local gym. Vitals signs obtained and labs drawn requested by provider. Which of the following 5 findings require immediate follow-up by the nurse? (Select all that apply.)
Correct Answer: A,D,E,F,G
Rationale: A. Sodium level: Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures. B. Phosphate level: While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical. C. Magnesium level: Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance. D. Respiratory rate: Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function. E. Capillary refill: Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns. F. Blood pressure: Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being. G. Glucose level: Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client.
Question 2 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.
Extract:
Diagnostic Results: Sodium: 135 mEq/L (expected reference range 136 to 145 mEq/L), Potassium 2.9 mEq/L (expected reference range 3.5 to 5 mEq/L), Chloride: 94 mEq/L (expected reference range 98 to 106 mEq/L), Phosphate: 3.1 mg/dL (expected reference range 3 to 4.5 mg/dL), Magnesium: 2 mg/dL (expected reference range 1.3 to 2.1 mg/dL), Glucose 74 mg/dL (expected reference range 74 to 106 mg/dL).
Question 3 of 5
A nurse working in a mental health facility is admitting a client. Exhibits: A nurse is assisting with initiating the client's plan of care. Complete the following sentence by using the list of options (Separate using a comma). The nurse should first address the client's ___ followed by the client's ___
Correct Answer: A,B
Rationale: The nurse should first address the client's cardiac status followed by the client's nutritional status. Cardiac status: Potassium levels are critically low, which can significantly impact cardiac function. Nutritional status: The client has multiple electrolyte imbalances, which could be related to nutrition or absorption issues.
Extract:
Question 4 of 5
A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?
Correct Answer: C
Rationale: Everyone has trouble sleeping at times' minimizes the client's concerns and may not address the underlying issues contributing to their anxiety. 'Why do you think you are so anxious?' might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings. 'Have you talked to your provider about this yet?' This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions. 'It sounds like you're having a difficult time' acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.
Question 5 of 5
A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?
Correct Answer: D
Rationale: Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning. A client who is giving away their possessions. Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.