ATI LPN Mental Health 2023 II

ATI LPN Mental Health 2023 II Related

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Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)

A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.

  • A. Delirium,Depression,Alzheimer's disease,Generalized anxiety disorder
  • B. Encourage family members to stay with the client,Assist the client to identify coping skills,Monitor the client's fluid intake and output,Encourage the client to exercise.
  • C. Suicidal ideation,Weight loss,Fall risk,Sleep-wake cycle
Correct Answer: A

Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.

You may also like to solve these questions

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

  • A. Discuss the benefits of relaxation exercises with the client.
  • B. Explain the use of response prevention to the client.
  • C. Administer an antianxiety medication.
  • D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
Correct Answer: D

Rationale: Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions. This baseline data collection is the priority upon admission to tailor subsequent care.

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect?

  • A. Cold extremities.
  • B. Diarrhea.
  • C. Tooth erosion.
  • D. Lanugo.
Correct Answer: A,C,D

Rationale: Cold extremities, tooth erosion, and lanugo are common in anorexia nervosa. Poor circulation causes cold extremities, vomiting erodes teeth, and lanugo grows to conserve heat due to fat loss, reflecting the disorder’s physical impact.

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

  • A. Lanugo.
  • B. Muscle wasting.
  • C. Hypokalemia.
  • D. Hypomagnesemia.
Correct Answer: C

Rationale: Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated vomiting and laxative use. These behaviors lead to significant electrolyte imbalances, posing serious health risks.

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?

  • A. Can you see these spiders crawling all over me?
  • B. The aliens are going to abduct me tonight.
  • C. Are you planning to kill me?
  • D. The voices told me to quit eating the food here.
Correct Answer: D

Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

  • A. Request a consult with recreational therapy.
  • B. Lower the window shade in the client's room.
  • C. Place the client in a room close to the nurses' station.
  • D. Obtain a PRN prescription for a vest restraint.
Correct Answer: C

Rationale: Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls. This is a practical, non-restrictive measure to enhance safety.

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