ATI LPN
ATI LPN Mental Health Level 4 Exam Questions
Extract:
Question 1 of 5
A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?
Correct Answer: B
Rationale: The correct answer, indicated as B.
Rationale: Medication compliance is important but does not address the most immediate concerns for individuals with borderline personality disorder, such as self-harm. Awareness of the potential for self-harm is the priority because individuals with borderline personality disorder often engage in self-destructive behaviors. Resources for group therapy in the community are valuable but secondary to ensuring immediate safety. Insurance coverage is important but not urgent compared to the immediate need for safety and awareness of self-harm risks.
Question 2 of 5
A nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?
Correct Answer: B
Rationale: The correct answer, indicated as B.
Rationale: While the voices may be part of the illness, it is important to acknowledge the client's experience without dismissing it. Acknowledging the client's experience ('I know you hear the voices, but I do not') is important in establishing rapport and validating their reality. Asking how often the voices are heard can be useful, but acknowledging the client's perception should be the first priority. Asking what the voices are telling the client may come later, after the client's experience has been acknowledged.
Question 3 of 5
A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
Correct Answer: A
Rationale: The correct answer, indicated as A.
Rationale: Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another. While checking medications is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min).
Therefore, notifying the doctor of bradycardia is not appropriate in this case.
Question 4 of 5
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
Correct Answer: C
Rationale: The correct answer, indicated as C.
Rationale: Wrapping the blood pressure cuff snugly around the arm is correct, as the cuff needs to be secure to ensure an accurate reading. Centering the cuff bladder over the brachial artery is correct, as this is necessary for accurate blood pressure measurement. Placing the client's arm above the level of the heart is incorrect. The arm should be at heart level to ensure the accuracy of the reading. If the arm is elevated, it could result in a falsely low reading. Checking the instrument gauge to ensure the reading starts at zero is correct. This step is important to ensure the accuracy of the measurement.
Question 5 of 5
A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?
Correct Answer: B
Rationale: The correct answer, indicated as B.
Rationale: Hostility and sarcasm are concerning, but they are not as urgent as the risk of injury associated with hyperactivity. Pacing in the hallway during the day and night is indicative of extreme restlessness and may lead to exhaustion or self-harm. The nurse should address this behavior to prevent harm. Giving money away may be problematic, but it is a less immediate risk compared to physical safety. Flight of ideas is a common symptom of mania, but it is less dangerous than pacing and hyperactivity, which can lead to physical harm.