ATI LPN
ATI LPN Mental Health Exam IV Questions
Extract:
Question 1 of 5
An elderly male client is hospitalized immediately after attempting suicide. Which of the following is implemented as a suicide precaution?
Correct Answer: B
Rationale: Facilitate time alone for the client. Allowing time alone is not appropriate for a suicidal client as it increases the risk of self-harm. Make a no self-harm contract. A no self-harm contract can be part of a suicide prevention plan, where the client agrees to not harm themselves and to seek help if they feel the urge to do so. Administer antianxiety medication: While medication can help with anxiety, it is not a primary intervention for immediate suicide prevention. Prevent family/friend visitation for 48 hours: Preventing visitation can increase feelings of isolation and is not an appropriate intervention for suicide prevention.
Question 2 of 5
A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Pitting edema is a hallmark of venous insufficiency due to fluid leakage from high venous pressure. Thickened toenails (
A) are fungal-related, shiny skin (
B) and dusky color (
C) indicate arterial insufficiency. Edema reflects venous stasis.
Question 3 of 5
A nurse is assessing the therapeutic International Normalized Ratio (INR) range for a patient receiving Warfarin. Which INR range below is therapeutic?
Correct Answer: A
Rationale: INR 2.0–3.0 is the standard therapeutic range for warfarin in conditions like atrial fibrillation or DVT, balancing clot prevention and bleeding risk. 4.0–5.0 and 3.0–4.9 risk bleeding; 1.0–2.0 is subtherapeutic, risking clots. 2.0–3.0 aligns with clinical guidelines.
Question 4 of 5
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply)
Correct Answer: B, D, E
Rationale: Lisinopril, an ACE inhibitor, requires specific instructions:
B) Pregnancy is a contraindication due to fetal harm risk, necessitating immediate notification.
D) A persistent dry cough is a common side effect due to bradykinin buildup, requiring reporting. E) Blood pressure monitoring is essential to assess efficacy.
A) Cholesterol monitoring isn’t directly tied to lisinopril, which targets blood pressure, not lipids.
C) Potassium-rich foods should be moderated, not increased, due to hyperkalemia risk with ACE inhibitors.
Question 5 of 5
A nurse on a telemetry unit is reviewing the laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider?
Correct Answer: B
Rationale: PT of 45 seconds (normal 11–13.5 seconds) indicates excessive anticoagulation (therapeutic 1.5–2 times normal), risking bleeding on warfarin. Hgb (16 g/dL, 13.8–17.2 g/dL), aPTT (36 seconds, 21–35 seconds), and platelets (190,000/mm, 150,000–450,000/mm) are normal. PT requires urgent reporting.