ATI LPN Mental Health Level 4 Exam

Extract:

Question 1 of 5

A nurse is caring for a client who has delusional behavior. The client states, 'I can’t go to group today. I am expecting a high level official to visit me!' Which of the following responses should the nurse make?

A. Let’s walk together to group so we can discuss your concerns.' B. I think you should attend group therapy. We will talk about this when you’re done.' C. I wouldn’t worry about that. They will call you back later.' D. Why do you think you are getting a visit from someone today?'

Correct Answer: A

Rationale: The correct answer, indicated as A.
Rationale: Acknowledge the client’s delusion while gently redirecting them to the necessary activity (group therapy). This approach maintains engagement without directly confronting the delusion. Ignoring the delusion and focusing only on group therapy may cause the client to feel unheard or dismissed. Dismissing the delusion is not therapeutic and could undermine trust. Asking 'why' could challenge the delusion, leading to defensiveness rather than productive conversation.

Question 2 of 5

A nurse is assisting with planning of care for a client following a suicide attempt. Which of the following interventions is an appropriate suicide precaution?

A. Assign the client to a private room. B. Tuck bedcovers over client’s hands and arms. C. Remove all utensils from the client’s meal trays. D. Inspect the client’s personal belongings.

Correct Answer: D

Rationale: The correct answer, indicated as D.
Rationale: Assigning a private room may increase isolation, which is not conducive to a therapeutic environment. Tucking bedcovers over the client’s hands and arms could be a restrictive action, not appropriate for suicide prevention. Removing utensils is not necessary unless the client has direct access to harmful objects. Inspecting personal belongings ensures that the client does not have items that could be used for self-harm, which is a key suicide precaution.

Question 3 of 5

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

A. Wrap the blood pressure cuff snugly around the arm. B. Center the cuff bladder over the brachial artery. C. Place the client's arm above the level of the heart. D. Check the instrument gauge to ensure the reading starts at zero

Correct Answer: C

Rationale: The correct answer, indicated as C.
Rationale: Wrapping the blood pressure cuff snugly around the arm is correct, as the cuff needs to be secure to ensure an accurate reading. Centering the cuff bladder over the brachial artery is correct, as this is necessary for accurate blood pressure measurement. Placing the client's arm above the level of the heart is incorrect. The arm should be at heart level to ensure the accuracy of the reading. If the arm is elevated, it could result in a falsely low reading. Checking the instrument gauge to ensure the reading starts at zero is correct. This step is important to ensure the accuracy of the measurement.

Question 4 of 5

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A. pulse deficit B. diastolic C. auscultatory gap D. widened pulse pressure

Correct Answer: C

Rationale: The correct answer, indicated as C.
Rationale: A pulse deficit refers to a condition where there is a difference between the radial and apical pulse rates, not a phenomenon heard during blood pressure measurement. Diastolic pressure is the point at which sounds fade away or become muffled, but the silence between sounds refers to a different concept, not the actual diastolic pressure. An auscultatory gap is the term used to describe a silent interval between the systolic and diastolic sounds during blood pressure measurement. This can lead to inaccurately low readings if not identified. A widened pulse pressure refers to a larger-than-normal difference between systolic and diastolic pressure, which is not related to the auscultatory silence.

Question 5 of 5

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

A. check the patient's record to determine his baseline blood pressure. B. notify the charge nurse of the hypotension. C. check medications that might be the cause of the irregularity. D. notify the doctor of the bradycardia.

Correct Answer: A

Rationale: The correct answer, indicated as A.
Rationale: Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another. While checking medications is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min).
Therefore, notifying the doctor of bradycardia is not appropriate in this case.

ATI LPN Mental Health Level 4 Exam | Nurselytic

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