ATI LPN
ATI LPN Mental Health Exam IV Questions
Extract:
Question 1 of 5
A teenager is noted to have a heightened awareness of reality, feelings of depersonalization, unpredictable and sometimes violent behavior, and flashbacks. The nurse suspects that the teenager is taking which of the following chemicals?
Correct Answer: D
Rationale: Cannabis: While cannabis can alter perception and cause depersonalization, it is less likely to cause violent behavior and flashbacks. Heroin: Heroin is a depressant that typically causes sedation and euphoria, not heightened awareness or violent behavior. Cocaine: Cocaine is a stimulant that can cause heightened awareness but is less associated with depersonalization and flashbacks. Phencyclidine (PCP): PCP is known to cause severe alterations in perception, depersonalization, unpredictable and violent behavior, and flashbacks.
Question 2 of 5
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly one of the client's jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Ignore the incident since it is an attention-seeking behavior: Ignoring the incident is not appropriate because the client may be in distress or at risk of harm. Stay with the group and ask another client to go and check on the situation: Asking another client to check on the situation is not appropriate, as it is the nurse's responsibility to ensure the safety of all clients. Follow the client to determine the cause of the behavior: Following the client allows the nurse to assess and intervene appropriately to ensure the client's safety and address the cause of the behavior. Ask the group what they think about the client's behavior: Discussing the behavior with the group is not appropriate in an emergency situation and does not address the immediate needs of the distressed client.
Question 3 of 5
A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Checking pedal pulses every 15 minutes monitors perfusion post-femoral catheterization, detecting occlusion or bleeding. High-Fowler’s (
A) risks bleeding, ambulation (
B) is premature, and ROM (
D) disrupts site stability. Pulses ensure vascular integrity.
Question 4 of 5
A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?
Correct Answer: B
Rationale: Hyperkalemia (6.8 mEq/L, normal 3.5–5.0 mEq/L) from spironolactone (a potassium-sparing diuretic) risks cardiac arrhythmias. A 12-lead ECG detects changes (e.g., peaked T waves). ESR is unrelated, more potassium worsens hyperkalemia, and fluid restriction doesn’t address potassium levels. ECG is urgent for cardiac monitoring.
Question 5 of 5
A husband is yelling and swearing at his wife during an argument. He also is pacing and pounding his fist. This pattern of behavior is consistent with which stage in the assault cycle?
Correct Answer: C
Rationale: Recovery stage: The recovery stage occurs after the crisis has passed and the individual begins to calm down and return to baseline behavior. Crisis stage: The crisis stage involves the peak of aggression, often resulting in physical violence. Escalation stage: The escalation stage involves increasing agitation and aggressive behaviors, such as yelling, swearing, pacing, and fist-pounding, before reaching a crisis. Trigger stage: The trigger stage involves the initial event or situation that provokes the individual's anger or aggression.