ATI LPN
ATI LPN Mental Health Level 4 test II Questions
Extract:
Question 1 of 5
A nurse is collecting the medical history of a client. The client reports that they have experienced violence in the past with a previous partner. What is an immediate concern of the nurse?
Correct Answer: A
Rationale: The client reports that they have no social support system, but has an appointment with a caseworker in two weeks. Lack of a social support system poses a risk for isolation, depression, and potential difficulty accessing resources. Immediate intervention may be required to provide emotional and practical support. The client reports that they are experiencing frequent gastrointestinal issues: While important, these may be psychosomatic and can be addressed after ensuring the client's emotional and physical safety. The client reports that they are currently living in a safe place: Being in a safe environment is reassuring and not an immediate concern. The client reports that they are currently going to counseling: Ongoing counseling is a positive step toward healing and does not require immediate intervention.
Question 2 of 5
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions is the nurse's priority?
Correct Answer: D
Rationale: Offer the client high-calorie fluids: This is not a priority during a panic attack. Addressing physical needs comes later. Administer an antianxiety medication to the client: Medication may be part of treatment but is not the immediate priority. Teach the client relaxation exercises: Relaxation exercises are valuable but should be introduced after the acute phase of the panic attack has passed. Remain with the client in a quiet area. Remaining with the client provides reassurance, safety, and emotional support, which are critical during a panic attack.
Question 3 of 5
A nurse in the emergency department is caring for a client who reports having experienced sexual abuse. The nurse should identify which of the following findings are consistent with the client's report? (Select All that Apply.)
Correct Answer: A,B,C,E
Rationale: The client has anal bleeding: Physical trauma such as bleeding may occur from sexual abuse. B. The client complains of pelvic soreness: Pelvic soreness is a common physical manifestation following sexual assault. C. The client has bruising around the breasts: Bruising in areas commonly targeted during assault can indicate abuse. D. The client has a scar on their inner thigh: A scar is indicative of past injury but does not directly confirm recent sexual abuse. E. The client's underwear is bloody: Blood-stained undergarments may be evidence of trauma.
Question 4 of 5
A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?
Correct Answer: B
Rationale: A 6-year-old child who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle: This injury is consistent with a common childhood accident and does not strongly suggest abuse. A 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water: This explanation is implausible for a 9-month-old, as infants lack the motor skills and strength to climb into a tub and turn on water, raising suspicion of abuse or neglect. A 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself: This is a plausible accident for a curious toddler and does not immediately suggest abuse. A 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows: Bruises in these areas are typical for a toddler learning to walk and do not strongly indicate abuse.
Question 5 of 5
A nurse working at a middle school suspects that a student is experiencing physical abuse after collecting data from the student. Which of the following actions should the nurse take next?
Correct Answer: A
Rationale: Make a report to Child Protective Services (CPS). Nurses are mandated reporters and must report suspected abuse to the appropriate authorities, such as CPS, to ensure the safety of the child. Call the police and report the suspected abuse: While police involvement may be necessary, CPS is the primary agency for child welfare and abuse cases. Alert the school office to call parents: Informing the parents could place the child at further risk if the parents are the perpetrators. Call the child's guardian to have the child's pediatrician confirm the suspected abuse: This delays reporting and does not ensure immediate intervention to protect the child.