a nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision a nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision
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Nursing Elites

ATI LPN

ATI Mental Health Proctored Exam 2019

1. A client in an acute mental health facility is being discharged and requires supervision due to a severe mental illness. The client’s partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care?

Correct answer: C

Rationale: For clients requiring supervision due to severe mental illness, attending a partial hospitalization program provides structured care and support while allowing the client to return home in the evenings, making it a suitable option for follow-up care. The other choices are less appropriate: A home health aide may not provide the necessary level of care and supervision, a weekly visit from a nurse case worker may not be sufficient for the client's needs, and visiting a community mental health center on a daily basis may not offer the structured support required for someone with a severe mental illness.

2. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

3. A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?

Correct answer: B

Rationale: In a client with uterine hypotonicity and postpartum hemorrhage, the priority is to address the risk of hypovolemic shock, which can lead to vital organ perfusion compromise and potentially death. Massaging the client's fundus helps to control bleeding by promoting uterine contraction and reducing blood loss, making it the nurse's priority intervention in this situation. Checking capillary refill may be important in assessing perfusion status but is not the priority over controlling the hemorrhage. Inserting an indwelling urinary catheter is not the priority in managing postpartum hemorrhage. Although preparing for a blood transfusion may be necessary, addressing the primary cause of bleeding by massaging the fundus takes precedence to stabilize the client's condition.

4. What action should be taken to prevent respiratory complications in a client who is postoperative?

Correct answer: A

Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.

5. What are common signs of hypoglycemia?

Correct answer: A

Rationale: The correct signs of hypoglycemia include shakiness or tremors, sweating, and hunger. These symptoms indicate low blood sugar levels. Confusion or irritability are more associated with severe hypoglycemia, while the immediate treatment for hypoglycemia involves providing a source of glucose to raise blood sugar levels quickly.

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