ATI LPN Mental Health Level 4 Exam

Extract:

Question 1 of 5

A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

A. Communicate to the client that it is acceptable to cry. B. Determine the client’s stage of grief. C. Encourage the client to express feelings openly, D. Enable the client to obtain spiritual support.

Correct Answer: B

Rationale: The correct answer, indicated as B.
Rationale: While crying may be a normal expression of grief, determining the client’s stage of grief is more important for assessing the client’s emotional needs. Determining the client’s stage of grief is the first step to understanding the client’s emotional state and providing appropriate support. Encouraging expression is important, but first, understanding the client’s grief stage will guide the intervention. Spiritual support is valuable, but first, understanding the client’s emotional response is necessary before offering this type of assistance.

Question 2 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 3 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 4 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 5 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.

ATI LPN Mental Health Level 4 Exam | Nurselytic

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