ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
A nurse in a mental health facility is caring for a client.
Medical History: Antisocial personality disorder.
Substance use disorder.
Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.
Client states, "That judge is so stupid.
I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.
Extra staff members gather.
1500: Client escorted to room.
Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.
Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.
States, "I'm not sitting down with a bunch of nuts.
Question 1 of 5
Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
| anticipated | contraindicated |
|---|---|
| Use bargaining to improve behavior. | |
| Provide rewards for positive behavior. | |
| Ignore negative behavior. | |
| Maintain a low-stimuli environment. |
Correct Answer:
Rationale: Rewards for positive behavior (
B) and low-stimuli environment (
D) are anticipated for antisocial personality disorder. Bargaining (
A) reinforces manipulation, and ignoring negative behavior (
C) avoids accountability.
Extract:
Question 2 of 5
A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?
Correct Answer: B
Rationale: Early recognition facilitates timely intervention for NSSH. Discouraging discussion (
A), labeling as attention-seeking (
C), and immediate questioning (
D) are unhelpful.
Question 3 of 5
A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
Correct Answer: A
Rationale: Twisting tongue movements are characteristic of tardive dyskinesia. Shuffling gait (
B) is parkinsonism, fever (
C) is NMS, and tapping (
D) is akathisia.
Question 4 of 5
A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?
Correct Answer: A
Rationale: The correct answer is A: GI discomfort and poor coordination. A serum lithium level of 1.6 mEq/L indicates lithium toxicity. The gastrointestinal (GI) system is commonly affected by lithium toxicity, causing symptoms like nausea, vomiting, diarrhea, and abdominal pain. Poor coordination can occur due to the neurologic effects of lithium toxicity. Lip smacking and tongue thrusting (
B) are associated with tardive dyskinesia, not lithium toxicity. Blurred vision and jerking motor movements (
C) are not typical manifestations of lithium toxicity. Fever and fluctuating blood pressure (
D) are not commonly seen with lithium toxicity.
Question 5 of 5
A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Risperidone is an atypical antipsychotic medication known to cause weight gain as a common side effect. This is due to its impact on appetite regulation and metabolic processes. Bradycardia (
B), nightmares (
C), and dependent edema (
D) are not commonly associated with risperidone use. Weight gain is a significant side effect that the nurse should monitor and address to promote the client's overall health.