ATI LPN Mental Health 2023

Extract:

Question 1 of 5

A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

A. A client who has borderline personality disorder and acts impulsively B. A client who has avoidant personality disorder and becomes anxious in social situations C. A client who has dependent personality disorder and clings to nursing staff D. A client who has histrionic personality disorder and seeks constant attention

Correct Answer: A

Rationale: Clients with borderline personality disorder (BP
D) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support.

Question 2 of 5

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

A. I remember how depressed I was after my friend died. B. You should start participating in your usual activities. C. Everyone feels depressed during the grieving process. D. Tell me what your relationship with your partner was like.

Correct Answer: D

Rationale: This response opens a conversation about the client’s feelings and experiences, showing empathy and a willingness to understand their perspective. It helps build trust and rapport, allowing the nurse to provide appropriate support.

Question 3 of 5

A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

A. Use a quick-release tie to restrain the client. B. Renew the restraint prescription every 48 hr. C. Attach the restraints to the side rail of the client's bed. D. Maintain 1 fingerbreadth between the restraint and the client's skin.

Correct Answer: A

Rationale: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety.

Question 4 of 5

A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?

A. Determine whether the client's goals are met. B. Collect data about the client's current health status. C. Provide the client with information on problem-solving. D. Establish a regular meeting time with the client.

Correct Answer: C

Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.

Question 5 of 5

A nurse is reinforcing teaching with a client who is scheduled for implantation of a vagus nerve stimulator. Which of the following statements should the nurse include in the teaching?

A. You might have extreme fatigue for several weeks after the device is implanted. B. Your voice might sound hoarse after the device is implanted. C. Your depression will improve within 72 hours after the device is implanted. D. You can schedule an appointment with your provider to turn the device off.

Correct Answer: B

Rationale: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.

ATI LPN Mental Health 2023 | Nurselytic

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ATI LPN

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