ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 of 5
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.
Question 2 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 3 of 5
A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?
Correct Answer: C
Rationale: Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation. Pupillary constriction (miosis). Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
Question 4 of 5
A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
Correct Answer: A
Rationale: The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended. Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm. Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others. Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or others.
Question 5 of 5
A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa. Physical Examination: Client appears preoccupied and displays poor concentration but is oriented X3. Client has very thin appearance, measuring 5 feet 2 inches tall and weighing 42.6 kg (94 lb). This calculates to 81% of ideal target weight. Client skin color is pallor with capillary refill greater than 2 seconds. When asked about fainting, client minimizes it and comments, 'I was just tired. it was nothing.' Which of the following 5 findings require immediate follow-up by the nurse?
Correct Answer: A,B,D
Rationale: A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa. B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent. D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention. E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances. F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first. G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.