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 who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels. Significant change in weight. Major depressive disorder (MD
D) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.
Extract:
Graphic Record 0800: Blood pressure 118/76 mm Hg, Temperature 36.9°C (98.4°F), Heart rate 88/min, Respiratory rate 18/min. 1300: Blood pressure 116/74 mm Hg, Temperature 37.7°C (99.9°F), Heart rate 96/min, Respiratory rate 16/min
Question 3 of 5
. A nurse is assisting with the care for a newly admitted client who has major depressive disorder. Select 1 condition and 1 client finding to fill in the following sentence (Separate using a comma). The client is at risk for developing ___ due to the Client's intake of ___
Correct Answer: C,B
Rationale: The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort. St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body. In the given scenario, the nurse should identify: Condition: The client's intake of St. John's wort; Client Finding: At risk for developing serotonin syndrome. This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.
Extract:
Question 4 of 5
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?
Correct Answer: A
Rationale: I should sit on the side of the bed before standing up in the morning.' Amitriptyline is a tricyclic antidepressant that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing.
To minimize the risk of dizziness or fainting, clients taking amitriptyline should be advised to sit on the side of the bed for a few moments before standing up, especially in the morning when orthostatic changes may be more pronounced. 'I may experience an increased libido.' This statement is not related to the common side effects of amitriptyline. Changes in libido are not typically associated with this medication. 'I will avoid drinking caffeinated beverages.' While it's generally a good idea to limit caffeine intake, this statement is not a specific instruction related to amitriptyline. However, reducing caffeine consumption can be beneficial because amitriptyline may enhance the stimulant effects of caffeine. 'I can no longer eat pepperoni pizza.' This statement is not directly related to amitriptyline. There are no specific dietary restrictions associated with amitriptyline use, and the client can continue to eat pepperoni pizza unless there are individual dietary concerns or interactions with other medications.
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. 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.