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 assisting in the care of a client who has chronic stress. The client states. 'I always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect. 'Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?' This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies. Encouraging the use of alcohol as a way to 'take the edge off' is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.
Question 3 of 5
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.
Question 4 of 5
A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?
Correct Answer: C
Rationale: Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation. Pupillary constriction (miosis). Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
Question 5 of 5
A nurse is caring for a client who was recently diagnosed with an opioid use disorder. They were a student in a local community college but were recently dismissed for failing their classes. Their previous diagnoses include anxiety, Crohn's disease, and chronic back pain due to a gymnastics injury in high school. Which of the following should the nurse identify as potential underlying reasons why the client might have started using opioids?
Correct Answer: D
Rationale: Using opioids to treat hallucinations is not a common reason, as opioids are not typically prescribed for this purpose. Hallucinations might be indicative of another underlying mental health condition that needs assessment and appropriate treatment. Witnessing parents using drugs or alcohol to cope is a risk factor for substance use disorders, but it does not directly explain the client's initiation of opioid use. There may be other contributing factors, such as pain or anxiety. Using opioids to promote sleep and rest is a possibility, especially if the client has chronic pain or anxiety affecting their sleep. Opioids can have sedative effects, which might be appealing to individuals experiencing sleep difficulties. However, treating pain and anxiety is often a primary reason for opioid use in such cases.
To treat pain and ease anxiety. Chronic back pain due to a gymnastics injury and anxiety are identified as pre-existing conditions. The client may have started using opioids to manage chronic pain and potentially as a way to cope with anxiety. Opioids are often prescribed for pain relief, and individuals may misuse them to self-medicate emotional distress.