ATI LPN
ATI Mental Health Practice A 2023
1. A patient with obsessive-compulsive disorder (OCD) spends hours washing their hands. Which nursing intervention is most appropriate?
- A. Encouraging the patient to stop washing their hands
- B. Allowing the patient to wash hands at specified times
- C. Ignoring the patient's behavior
- D. Setting strict limits on the time allowed for hand washing
Correct answer: B
Rationale: In managing a patient with OCD who spends excessive time washing hands, allowing the patient to wash hands at specified times is the most appropriate nursing intervention. This approach helps establish a structured routine for hand washing, which can assist in managing OCD symptoms without reinforcing the behavior. Encouraging the patient to stop washing hands may lead to increased anxiety and resistance. Ignoring the behavior can perpetuate the cycle of OCD, and setting strict limits on hand washing time may cause distress and may not effectively address the underlying issues associated with OCD.
2. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?
- A. Shave the front of the client's chest
- B. Give the client a device holder to wear around the waist
- C. Teach the client to rest as much as possible during the next 24 hours
- D. Tell the client to cover the monitor in plastic wrap before taking a bath
Correct answer: B
Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.
3. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
- A. Your weight gain should be less than that for someone without diabetes.
- B. Your weight gain should be the same as that for someone without diabetes.
- C. You should not avoid gaining weight during pregnancy.
- D. You should gain more weight to support the pregnancy.
Correct answer: B
Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.
4. A nurse is providing discharge instructions for a client using home oxygen. What is the most important safety measure?
- A. Store oxygen tanks in a closet when not in use
- B. Ensure that oxygen tanks are kept upright and away from heat sources
- C. Allow family members to smoke in designated areas
- D. Restrict fluid intake while using oxygen
Correct answer: B
Rationale: The correct answer is B: Ensure that oxygen tanks are kept upright and away from heat sources. This is the most important safety measure to prevent accidents related to home oxygen use. Storing oxygen tanks in a closet when not in use (choice A) is not recommended as they should be stored in a well-ventilated area. Allowing family members to smoke in designated areas (choice C) poses a significant fire hazard. Restricting fluid intake while using oxygen (choice D) is not a safety measure related to oxygen use.
5. A client with a history of urinary tract infections (UTIs) is being cared for by a nurse. Which of the following instructions should the nurse provide to prevent future infections?
- A. Wipe from front to back after urination
- B. Drink 2-3 liters of water per day
- C. Avoid holding urine for long periods
- D. Wear loose-fitting underwear
Correct answer: B
Rationale: The correct answer is to advise the client to drink 2-3 liters of water per day. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of UTIs. Choice A is incorrect because wiping from front to back is the appropriate technique to prevent the spread of bacteria from the rectal area to the urethra. Choice C is incorrect as holding urine for long periods can contribute to UTIs by allowing bacteria to grow in the bladder. Choice D is incorrect as wearing loose-fitting underwear is recommended to allow air circulation and prevent moisture buildup, reducing the risk of UTIs.
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