ATI LPN
ATI LPN Mental Health Level 4 test II Questions
Extract:
Question 1 of 5
A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Invite a family member to be present for the nursing history: This may discourage the client from sharing truthful information if the family member is the perpetrator. Display disapproval toward the perpetrator: Displaying judgment can increase the client's distress and reduce their openness. Probe the client to offer a factual account of the abuse: Pressuring the client to share details can retraumatize them. Be direct and honest when communicating with the client. Direct, honest communication helps build trust, which is essential for abused clients who may feel vulnerable.
Question 2 of 5
A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?
Correct Answer: B
Rationale: A 6-year-old child who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle: This injury is consistent with a common childhood accident and does not strongly suggest abuse. A 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water: This explanation is implausible for a 9-month-old, as infants lack the motor skills and strength to climb into a tub and turn on water, raising suspicion of abuse or neglect. A 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself: This is a plausible accident for a curious toddler and does not immediately suggest abuse. A 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows: Bruises in these areas are typical for a toddler learning to walk and do not strongly indicate abuse.
Question 3 of 5
A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The client is easily startled by loud voices. Hypervigilance and being easily startled are hallmark symptoms of PTSD. The client talks constantly about the traumatic experience: Clients with PTSD often avoid discussing their trauma. The client reports satisfying personal relationships with family and close friends: PTSD can strain relationships due to emotional withdrawal and hypervigilance. The client is constantly drowsy and sleeps 11-12 hours daily: Clients with PTSD often experience insomnia or sleep disturbances, not prolonged sleep.
Question 4 of 5
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions is the nurse's priority?
Correct Answer: D
Rationale: Offer the client high-calorie fluids: This is not a priority during a panic attack. Addressing physical needs comes later. Administer an antianxiety medication to the client: Medication may be part of treatment but is not the immediate priority. Teach the client relaxation exercises: Relaxation exercises are valuable but should be introduced after the acute phase of the panic attack has passed. Remain with the client in a quiet area. Remaining with the client provides reassurance, safety, and emotional support, which are critical during a panic attack.
Question 5 of 5
A nurse is caring for a client who has panic disorder. The client tells the nurse she is suddenly feeling very apprehensive, has a sense that something catastrophic is going to happen, and that she sees bugs flying around her room. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Reinforce reality with the client. While reinforcing reality can help in addressing the client's hallucinations (seeing bugs), it may not be the immediate priority when the client is experiencing severe panic. Instruct the client to take deep breaths: Helping the client to take deep breaths can provide immediate relief from acute anxiety by promoting relaxation and helping to reduce the physiological symptoms of panic. Once the client is calmer, other interventions can be considered. Assist the client to identify the cause of the anxiety: Insight into triggers is more appropriate after the acute episode resolves. Administer an antianxiety medication to the client: While this may be necessary, it is not the immediate first action in this scenario.