ATI LPN
ATI Mental Health Practice A 2023
1. A patient with obsessive-compulsive disorder (OCD) performs hand washing repeatedly. Which nursing intervention is most appropriate?
- A. Restricting the patient from washing hands
- B. Setting strict limits on the patient's hand washing
- C. Allowing the patient to wash hands at specified times
- D. Ignoring the patient's behavior
Correct answer: C
Rationale: Allowing the patient to wash hands at specified times is the most appropriate nursing intervention for a patient with OCD who repetitively performs hand washing. This intervention provides structure by allowing the patient to engage in the behavior at designated times, helping to reduce the compulsion gradually. Restricting or setting strict limits may increase anxiety and worsen the condition, while ignoring the behavior does not address the underlying issue of OCD.
2. To form a core support group of nurses, where should the nurse organizer conduct meetings to gather initial information?
- A. Away from the work site with a group of managers to learn both sides of the situation
- B. In homes or local businesses with staff nurses
- C. At the facility to discuss nursing concerns
- D. At the work site with staff nurses who are respected leaders
Correct answer: B
Rationale: The correct approach is to conduct meetings in homes or local businesses with staff nurses. This location ensures confidentiality, prevents management influence, and allows the focus to be on gathering support for forming a core support group. Choice A is incorrect as involving managers may compromise the independence and authenticity of the group. Choice C is incorrect as conducting meetings at the facility may not provide a secure and unbiased environment for open discussions. Choice D is incorrect because holding meetings at the work site with respected leaders may lead to biased opinions and hinder open communication.
3. A healthcare professional is preparing to administer a subcutaneous injection of insulin. Which of the following actions should the professional take?
- A. Use a 1-inch needle.
- B. Insert the needle at a 90-degree angle.
- C. Use a tuberculin syringe.
- D. Aspirate before injecting.
Correct answer: B
Rationale: When administering a subcutaneous injection, inserting the needle at a 90-degree angle is appropriate. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Using a 1-inch needle is common for subcutaneous injections to reach the subcutaneous fat layer adequately. Tuberculin syringes are typically used for intradermal injections, not subcutaneous injections. Aspirating before injecting is not necessary for subcutaneous injections as it is primarily used for intramuscular injections to ensure the needle is not in a blood vessel.
4. A client in a family planning clinic requests oral contraceptives. Which of the following findings in the client's history should be recognized as contraindications to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Migraine headaches
- D. All of the above
Correct answer: D
Rationale: Cholecystitis is a correct answer. A history of gallbladder disease, such as cholecystitis, is a contraindication for the use of oral contraceptives. Hypertension is a correct answer. Hypertension is also a contraindication for the use of oral contraceptives due to the increased risk of complications. Migraine headaches are a correct answer. A history of migraine headaches is a contraindication for the use of oral contraceptives, especially for those with aura. Selecting 'All of the above' is correct as all the mentioned conditions (cholecystitis, hypertension, and migraine headaches) are contraindications for oral contraceptives. Human papillomavirus and anxiety disorder are incorrect choices as they are not contraindications for the use of oral contraceptives.
5. A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor daily fluid intake
- B. Monitor blood glucose levels
- C. Measure intake and output
- D. Administer insulin as prescribed
Correct answer: B
Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.
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