ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
Medical History: Borderline personality disorder.
Alcohol use disorder.
History of suicidal ideation.
Medication Administration Record: Fluoxetine 20 mg PO daily.
Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.
Client reports recent breakup of romantic relationship and subsequent job loss.
States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.
Client states, "I feel so alone.
Question 1 of 5
There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
| anticipated | nonessential | contraindicated |
|---|---|---|
| Instruct the client to avoid foods with tyramine. | ||
| Apply wrist restraints. | ||
| Offer sympathy and attention to maladaptive behavior. | ||
| Encourage the client to talk about feelings prior to maladaptive behavior. | ||
| Maintain same staff members caring for the client. |
Correct Answer:
Rationale: Encouraging feelings (
D) and consistent staff (E) are anticipated. Tyramine avoidance (
A) is for MAOIs, restraints (
B) are a last resort, and sympathy to maladaptive behavior (
C) reinforces negativity.
Extract:
Question 2 of 5
A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?
Correct Answer: A
Rationale: Muscle weakness indicates mild lithium toxicity. Constipation (
B), urinary retention (
C), and hyperactivity (
D) are not typical symptoms.
Extract:
Medication Administration Record
• Naltrexone 50 mg PO once daily.
• Fluoxetine 20 mg PO every morning.
Diagnostic Results
• Hepatitis Viral Study (HAA): Positive (Expected Reference Range: Negative)
• Sodium Level: 131 mEq/L (Expected Reference Range: 136 to 145 mEq/L)
• Calcium Level: 9.5 mg/dL (Expected Reference Range: 9 to 10.5 mg/dL)
• BUN (Blood Urea Nitrogen): 11 mg/dL (Expected Reference Range: 10 to 20 mg/dL)
• Fasting Blood Glucose Level: 82 mg/dL (Expected Reference Range: 74 to 106 mg/dL)
• Hematocrit (Hct): 44% (Expected Reference Range: 37 to 52%)
• Hemoglobin (Hgb): 14 g/dL (Expected Reference Range: 12 to 18 g/dL)
History and Assessment
• Client has been admitted to the facility three times within the last 12 months.
• Client shows marked emotional lability and difficulty controlling their impulses.
• Client reports having multiple sexual partners and denies use of condoms.
• Client also acknowledges spending "a lot of money lately" and is not sure how they will pay for their current bills.
• Client admits to participating in self-harming behaviors (cutting) in the past to soothe themselves when feeling anxious.
• No evidence of recent self-harm.
• Client has recently experienced the loss of their remaining living parent and has reported an increased use of alcohol and recreational intravenous drugs to "numb the pain.”. Nurses Notes: Skin is warm and dry.
• Sclera are bloodshot.
• Client is unsteady on their feet, restless, and tense.
• Client reports drinking "a lot of whiskey" within the last 24 hrs.
• Presence of alcohol noted on the client's breath.
• Client is asking for "my nerve" pill.
• Evidence of old healed scratches/cuts noted on the arms and legs.
• States, "I don't have any money to pay for this!" When asked about living family members, states, "everyone is dead, life stinks.”.
Question 3 of 5
A nurse is caring for a client who has borderline personality disorder (BPD). Check the 6 assessment findings that require immediate follow-up:
Correct Answer: A,B,C,E,G
Rationale: Increased substances (
B), risky sexual behaviors (
C), positive hepatitis (
D), low sodium (G), frequent admissions (H), and loss of parent (I) require follow-up. Financial situation (
A), normal BUN (E), and Hgb (F) do not.
Extract:
Question 4 of 5
A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: Having consistent unit routines provides stability and predictability, beneficial for mania. Stimulating environments (
B) can worsen symptoms, seclusion (
C) may cause isolation, and discouraging napping (
D) risks fatigue.
Question 5 of 5
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder. (Select all that apply.)
Correct Answer: A,B,C,E
Rationale: Lithium (
A), valproate (
B), carbamazepine (
C), and paroxetine (E) are used for bipolar disorder. Donepezil (
D) is for Alzheimer's disease and not typically used.