ATI LPN
ATI Mental Health Proctored Exam 2019
1. In an emergency mental health facility, a nurse is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
- A. A client with schizophrenia who has delusions of grandeur
- B. A client with manifestations of depression who attempted suicide a year ago
- C. A client with borderline personality disorder who assaulted a homeless man with a metal rod
- D. A client with bipolar disorder who paces quickly around the room while talking to themselves
Correct answer: C
Rationale: The correct answer is C. A client with borderline personality disorder who has committed an assault poses a risk to others and themselves, necessitating temporary emergency admission for safety and further assessment. Choices A, B, and D do not indicate an immediate risk to self or others that would require temporary emergency admission.
2. When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?
- A. A client who has mitral valve prolapse
- B. A client who has been exposed to AIDS
- C. All pregnant clients
- D. A client who has a history of preterm labor
Correct answer: C
Rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is recommended for all pregnant clients to assess the risk of neural tube defects. It is a routine screening test used to detect increased levels of alpha-fetoprotein in maternal blood, which may indicate a higher risk for conditions such as neural tube defects in the developing fetus. Therefore, all pregnant clients, regardless of their medical history or risk factors, should undergo MSAFP screening as part of routine prenatal care. Choices A, B, and D are incorrect because the MSAFP screening is not specific to certain medical conditions or histories; it is a standard screening procedure for all pregnant individuals to evaluate neural tube defect risk in the fetus.
3. A client with diabetes is experiencing hyperglycemia. What is the nurse's priority?
- A. Administer insulin
- B. Encourage the client to exercise to lower blood glucose
- C. Encourage the client to drink water
- D. Administer glucagon
Correct answer: A
Rationale: The correct answer is to administer insulin. In hyperglycemia, there is an excess of glucose in the blood, which needs to be lowered. Insulin is the primary medication used to lower blood glucose levels by facilitating the uptake of glucose into cells. Encouraging the client to exercise may further increase blood glucose levels due to the release of stress hormones, so it is not the priority. While staying hydrated is important, it will not directly address the high blood glucose levels seen in hyperglycemia. Glucagon is used to treat severe hypoglycemia, not hyperglycemia, so it is not the priority in this situation.
4. A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Inject the medication in the lateral abdominal wall
- C. Massage the injection site to evenly distribute the medication
- D. Administer NSAIDs for injection site discomfort
Correct answer: B
Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.
5. What is the first step in managing a patient with a suspected pneumothorax?
- A. Insert a chest tube
- B. Monitor respiratory status
- C. Administer oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.
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