ATI LPN
ATI Mental Health Practice A 2023
1. A patient with bipolar disorder is experiencing a depressive episode. Which intervention is most appropriate?
- A. Encouraging the patient to participate in physical activities.
- B. Providing a stimulating environment to keep the patient engaged.
- C. Allowing the patient to isolate until they feel better.
- D. Encouraging the patient to express their feelings and concerns.
Correct answer: D
Rationale: During a depressive episode in bipolar disorder, it is essential to encourage patients to express their feelings and concerns. This intervention helps them feel heard, supported, and can aid in managing their emotions effectively.
2. A client has a new prescription for metformin. Which of the following instructions should the nurse include in the teaching?
- A. Take the medication at bedtime
- B. Monitor your blood glucose level before each meal
- C. Stop taking the medication if you develop muscle pain
- D. You may experience diarrhea with this medication
Correct answer: D
Rationale: The correct answer is D: 'You may experience diarrhea with this medication.' Diarrhea is a common side effect of metformin, particularly when initiating the medication. It is important for clients to be aware of this potential side effect. Option A is incorrect because metformin is usually taken with meals to reduce gastrointestinal side effects. Option B is not directly related to metformin use. Option C is incorrect as muscle pain is not a common side effect of metformin and does not warrant stopping the medication.
3. Which nursing intervention is essential for a client diagnosed with heart failure?
- A. Encourage fluid intake to prevent dehydration
- B. Monitor the client's weight daily to assess fluid balance
- C. Increase sodium intake to prevent fluid retention
- D. Limit fluid intake to avoid overload
Correct answer: B
Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.
4. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.
5. What intervention should the nurse encourage for a postpartum client complaining of perineal pain?
- A. Use of ice packs for the first 24 hours
- B. Application of heat packs immediately
- C. Avoiding the use of peri-bottles
- D. Using tampons to manage lochia
Correct answer: A
Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.
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