ATI LPN
LPN Custom Mental Health Questions
Extract:
Question 1 of 5
A nurse is talking with a client who has schizophrenia. Suddenly the client states, 'I'm frightened. Do you hear that? The voices are telling me to do terrible things.' Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: Why do you think you are hearing the voices?' This question may come across as confrontational and might make the client defensive. It's better to focus on the content of the hallucinations rather than questioning the client's perception. 'What are the voices telling you to do?' This response is appropriate because it acknowledges the client's experience, shows empathy, and encourages the client to express their thoughts and feelings. It is important to gather more information about the content of the hallucinations and delusions to understand the client's perception of reality. 'You need to tell the voices to leave you alone.' This response oversimplifies the experience of hallucinations and may not be helpful. Telling the client to dismiss the voices is unlikely to be effective and may lead to frustration. 'You need to understand that there are no voices.' Denying the client's experience is not therapeutic. It's essential to validate the client's feelings and explore their subjective experience rather than dismissing it outright.
Question 2 of 5
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, 'I'm feeling sad. I don't want to talk now.' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: It will help you feel better if you talk about it.' While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress. 'Come on out and get involved with the game the other clients are playing.' Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate. 'I'll stay with you for a few minutes.' This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability. 'I'll come back when you feel like talking.' This response leaves the client alone, which may be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.
Question 3 of 5
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?
Correct Answer: A
Rationale: Potassium 2.8 mEq/L. Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention. Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia. Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent. Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.
Question 4 of 5
A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, 'You are all angry at me and wish you could go out and have a drink.' The client's response is an example of which of the following defense mechanisms?
Correct Answer: C
Rationale: Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement. Projection: Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do[es not fit this description].
Question 5 of 5
A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practitioner see first?
Correct Answer: B
Rationale: A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes. A client taking clozapine who has a sore throat and mild fever. Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine.