ATI LPN
ATI LPN Mental Health Level 4 test II Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is collecting data from a 6-year-old child who has experienced violence at school. Which of the following data collection strategies should the nurse use?
Correct Answer: C
Rationale: Have the child carefully repeat the events of the trauma: Asking a young child to recount traumatic events can retraumatize them and is unlikely to yield accurate information due to developmental limitations. Interview the child without caregiver present: While some information may need to be gathered privately, involving caregivers can provide comfort and support unless the caregiver is suspected of being involved in the violence. Have toys or drawing materials available for the child. Using toys or drawing materials provides a nonthreatening way for the child to express their feelings and experiences, as children often communicate better through play or art rather than direct verbal interaction. Focus on the physical domain of health: While physical health is important, the emotional and psychological effects of trauma are equally critical to address.
Question 3 of 5
A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?
Correct Answer: B
Rationale: Limiting the amount of time available for interaction with others: While this may occur incidentally, it is not the primary motivation for the client's behavior. Decreasing anxiety to a tolerable level. Compulsive behaviors in OCD are typically performed to reduce or manage anxiety. Cleaning and organizing are common coping mechanisms for clients with OCD. Focusing attention on useful tasks: The behavior is driven by anxiety, not productivity or utility. Manipulating and controlling others' behavior: OCD compulsions are typically not manipulative; they are self-directed responses to internal distress.
Question 4 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 5 of 5
A client is pacing in the hallway with clenched fists and a flushed face. They are yelling and cursing loudly. Which phase of the aggression cycle is this client in?
Correct Answer: B
Rationale: Triggering: This phase involves initial stressors or triggers leading to aggression but lacks the intense behavioral and physical symptoms described. Escalation: The escalation phase is characterized by increasing tension, verbal aggression, and physical manifestations like pacing or clenched fists. The client's behavior suggests they are moving toward a potential crisis. Anger: Anger is an emotion, not a phase of the aggression cycle. It may be present during multiple phases. Crisis: The crisis phase involves loss of control and actual aggressive or violent actions, which has not occurred yet in this scenario.