ATI LPN
ATI LPN Mental Health Exam IV Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask?
Correct Answer: D
Rationale: What will you accomplish by taking your life?' This question is not therapeutic and may be perceived as judgmental or dismissive. 'What happened to you in the past to make you so desperate?' This question focuses on past events and may not address the immediate crisis. 'Why do you feel depressed enough to end your life?' This question is less direct and may not elicit a specific plan, which is crucial for assessing risk. 'How will you carry out your plan?' This question is direct and helps to determine if the client has a specific plan, which is a key factor in assessing the immediacy and severity of the suicide risk.
Question 2 of 5
A nurse is assisting with teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close?
Correct Answer: B
Rationale: S2, the “dub” sound, occurs when the aortic and pulmonic (semilunar) valves close at the end of systole. S1 is mitral and tricuspid closure. S3 indicates rapid ventricular filling (e.g., heart failure). S4 reflects atrial contraction against a stiff ventricle. S2 directly correlates with semilunar valve closure.
Question 3 of 5
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply)
Correct Answer: B, D, E
Rationale: Lisinopril, an ACE inhibitor, requires specific instructions:
B) Pregnancy is a contraindication due to fetal harm risk, necessitating immediate notification.
D) A persistent dry cough is a common side effect due to bradykinin buildup, requiring reporting. E) Blood pressure monitoring is essential to assess efficacy.
A) Cholesterol monitoring isn’t directly tied to lisinopril, which targets blood pressure, not lipids.
C) Potassium-rich foods should be moderated, not increased, due to hyperkalemia risk with ACE inhibitors.
Question 4 of 5
A nurse recognizes unexplained fussiness and irritability in an infant, as well as unexplained injuries. The nurse should suspect which of the following?
Correct Answer: D
Rationale: Sexual abuse: While sexual abuse can cause physical and emotional symptoms, the combination of unexplained injuries and fussiness/irritability is more suggestive of physical trauma. Neglect: Neglect involves failure to provide for the child's basic needs, which can lead to developmental issues, but is less likely to cause unexplained injuries. Munchausen syndrome by proxy: Munchausen syndrome by proxy involves a caregiver fabricating or inducing illness in a child for attention. It can cause unexplained injuries, but the focus is more on medical symptoms. Shaken baby syndrome: Shaken baby syndrome results from violently shaking an infant, leading to physical injuries, irritability, and fussiness. It fits the description of unexplained injuries and behavioral changes.
Question 5 of 5
An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?
Correct Answer: D
Rationale: Take a time-out: A time-out is generally used for de-escalating situations in less severe cases and may not be effective if the client is already physically aggressive and a risk to staff. Administer oral medication: Administering oral medication can help to calm the client, but it may not be immediately effective if the client is already aggressive and out of control. Call a family member or friend: Calling a family member or friend may provide emotional support, but it is not a direct intervention to address immediate physical aggression. Apply restraints: When a client is physically aggressive and poses a risk of injury to themselves or others, applying restraints may be necessary to ensure safety. This should be done following proper protocols and as a last resort.