ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 of 5
A nurse is collecting data from a client admitted to an inpatient mental health unit and has a new prescription for disulfiram (Antabuse). Which of the following information is most important for the nurse to obtain before administering this medication?
Correct Answer: D
Rationale: History of kidney disease is not as critical for disulfiram administration. The primary concern is related to hepatic metabolism. When the client last drank alcohol is relevant information, but it is not the most critical factor to consider before administering disulfiram. The primary mechanism of disulfiram is to inhibit the breakdown of acetaldehyde, leading to an unpleasant reaction if alcohol is consumed, regardless of when the client last drank. Whether the client has taken disulfiram before is important information, but it does not take precedence over the assessment of liver function. The history of liver disease is more directly related to the potential risks and adverse effects associated with disulfiram use. History of liver disease is crucial to assess before administering disulfiram because disulfiram is metabolized in the liver. Patients with a history of liver disease may have impaired liver function, and the medication may not be well-tolerated or could exacerbate existing liver issues.
Question 2 of 5
A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?
Correct Answer: B
Rationale: Loss of appetite is not a specific manifestation of lithium toxicity. However, gastrointestinal symptoms like nausea and vomiting can contribute to a decreased appetite. Vomiting and diarrhea. Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder.
Toxicity can occur, and symptoms can range from mild to severe. Vomiting and diarrhea are common early signs of lithium toxicity. As toxicity progresses, it can lead to more severe symptoms, such as tremors, confusion, and potentially life-threatening complications. Increased flatulence is not a typical manifestation of lithium toxicity. Gastrointestinal symptoms associated with lithium toxicity are more likely to include nausea, vomiting, and diarrhea. Increased urination is not a typical manifestation of lithium toxicity. Lithium can affect renal function, leading to decreased urine output, but it does not typically cause increased urination as a sign of toxicity.
Question 3 of 5
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?
Correct Answer: C
Rationale: Planning with the client for how he can better handle frustration (option
A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time. Placing the client in a monitored seclusion room until he is calm (option
B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps. Offer the client an antianxiety medication. When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented. Restraining the client to prevent injury to himself or others (option
D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.
Question 4 of 5
A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa. Nurses' Notes: Client brought to the ED by parent due to a fainting at home earlier this evening. Parent reports that client has been worried about their weight and been refusing to eat. Parent also reports client has been spending several hours at the local gym. Vitals signs obtained and labs drawn requested by provider. Which of the following 5 findings require immediate follow-up by the nurse? (Select all that apply.)
Correct Answer: A,D,E,F,G
Rationale: A. Sodium level: Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures. B. Phosphate level: While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical. C. Magnesium level: Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance. D. Respiratory rate: Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function. E. Capillary refill: Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns. F. Blood pressure: Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being. G. Glucose level: Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client.
Question 5 of 5
A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, 'You are all angry at me and wish you could go out and have a drink.' The client's response is an example of which of the following defense mechanisms?
Correct Answer: C
Rationale: Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement. Projection: Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do[es not fit this description].