Questions 54

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ATI LPN Mental Health 2023 II Questions

Extract:

Nurses' Notes
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air

Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)


Question 1 of 5

A nurse is caring for a 65-year-old male client in the emergency department (ED). Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.

Correct Answer: A,D,E

Rationale: Maintaining a low stimulation environment, approaching slowly, and frequent reorientation address delirium symptoms by reducing agitation, building trust, and improving orientation, based on the client’s confused state.

Extract:


Question 2 of 5

A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?

Correct Answer: D

Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.

Question 3 of 5

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer: 2.5

Rationale:
Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.

Question 4 of 5

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: A

Rationale: Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.

Question 5 of 5

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

Correct Answer: C

Rationale: Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated vomiting and laxative use. These behaviors lead to significant electrolyte imbalances, posing serious health risks.

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