ATI LPN
ATI Mental Health Practice A
1. When caring for a patient with dissociative identity disorder, which nursing intervention is a priority?
- A. Providing detailed education about the condition
- B. Monitoring for signs of self-harm or suicidal ideation
- C. Encouraging the patient to recall traumatic events
- D. Helping the patient develop a strong sense of identity
Correct answer: B
Rationale: When caring for a patient with dissociative identity disorder, the priority nursing intervention is to monitor for signs of self-harm or suicidal ideation. Ensuring patient safety is crucial, as individuals with this disorder may be at increased risk of self-harm or suicidal behaviors. Providing education about the condition is beneficial but ensuring immediate safety takes precedence. Encouraging the patient to recall traumatic events can be detrimental and should be done cautiously under professional guidance. While helping the patient develop a strong sense of identity is important in the long term, it is not the immediate priority when safety is a concern.
2. The nurse is preparing to administer an intravenous dose of potassium chloride to a client with hypokalemia. The nurse should monitor for which potential complication?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hypercalcemia
Correct answer: A
Rationale: When administering potassium chloride to a client with hypokalemia, the nurse should monitor for hyperkalemia. Potassium chloride supplementation aims to increase potassium levels in individuals with hypokalemia. However, excessive administration can lead to hyperkalemia, which can be a serious and potentially life-threatening complication. Monitoring potassium levels is crucial to prevent this adverse outcome. Hypokalemia (Choice B) is the condition being treated, so it is not a complication of treatment. Hypernatremia (Choice C) refers to high sodium levels and is not directly related to the administration of potassium chloride. Hypercalcemia (Choice D) is an elevated calcium level and is not a common complication associated with potassium chloride administration in hypokalemia.
3. The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. What intervention should the nurse do to effectively accomplish this goal?
- A. Provide a quiet and low-stimulus environment.
- B. Encourage the family to visit very frequently.
- C. Encourage the client to call friends and relatives each day.
- D. Recommend that the client watch TV as a constant diversion.
Correct answer: A
Rationale: The correct answer is A: Provide a quiet and low-stimulus environment. A calm and quiet environment can help reduce stress, which is beneficial in preventing the occurrence of chest pain in clients with angina. Choice B is incorrect because excessive or frequent visitations may lead to increased stress and agitation for the client. Choice C is incorrect as it may not always contribute to a calm environment and could potentially increase the client's stress levels. Choice D is inappropriate as watching TV constantly may not promote a quiet and low-stimulus environment, which is essential in managing angina pectoris.
4. A 50-year-old man presents with progressive jaundice, dark urine, and pruritus. Imaging reveals a mass in the head of the pancreas. What is the most likely diagnosis?
- A. Pancreatic cancer
- B. Chronic pancreatitis
- C. Gallstones
- D. Primary sclerosing cholangitis
Correct answer: A
Rationale: The presentation of progressive jaundice, dark urine, and pruritus along with a pancreatic mass, particularly in the head of the pancreas, strongly suggests pancreatic cancer as the most likely diagnosis. These symptoms are classic for obstructive jaundice caused by a mass in the head of the pancreas, making pancreatic cancer the most fitting choice.
5. A healthcare professional is assessing a client who has been taking isoniazid to treat tuberculosis. The healthcare professional should monitor the client for which of the following findings as an adverse effect of the medication?
- A. Diarrhea
- B. Blurred vision
- C. Hearing loss
- D. Jaundice
Correct answer: D
Rationale: Correct. Jaundice is a serious adverse effect of isoniazid due to liver damage. It is essential to monitor for signs of liver toxicity, such as jaundice, while the client is on this medication. Diarrhea is a common side effect of isoniazid, but it is not as serious as liver damage. Blurred vision and hearing loss are not typically associated with isoniazid use.
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