ATI RN
Use of Psychotropic Medications Questions
Question 1 of 5
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets 'really dizzy' and feels like she is going to fall over. The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D because the symptoms described by the patient suggest orthostatic hypotension, a condition where blood pressure drops when changing positions. Instructing the patient to get up slowly can help prevent dizziness and falls. Choice A is incorrect as tiredness does not directly address the dizziness upon standing. Choice B is incorrect as dehydration is not the likely cause of the symptoms described. Choice C is incorrect because a complete neurologic examination is not the first step for addressing orthostatic hypotension.
Question 2 of 5
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to:
Correct Answer: A
Rationale: The correct answer is A because asking the patient to lock her fingers and pull engages the upper motor neurons, potentially facilitating the reflex response. This technique, known as Jendrassik maneuver, can help in eliciting reflexes that were initially absent. It is important to try this before proceeding with further testing or documenting reflexes as 0. Choice B is incorrect as retesting immediately after the maneuver may yield a different result. Choice C is premature as further testing may not be necessary after trying the Jendrassik maneuver. Choice D is incorrect as documenting reflexes as 0 without attempting the Jendrassik maneuver could lead to an inaccurate assessment.
Question 3 of 5
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):
Correct Answer: D
Rationale: The correct answer is D: Decreased level of consciousness. The patient's confusion about his age and location after a head injury indicates disorientation, a classic sign of altered mental status. This is likely due to the head injury affecting his brain function, leading to impaired cognitive abilities. This finding raises concern for decreased level of consciousness, as the patient is unable to accurately perceive his age or location. Summary: A: Great sense of humor - This choice is incorrect as the patient's response is not a deliberate attempt at humor. B: Uncooperative behavior - This choice is incorrect as the patient's response is not indicative of intentional noncompliance. C: Inability to understand questions - This choice is incorrect as the patient's response suggests more than just a simple misunderstanding of questions.
Question 4 of 5
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?
Correct Answer: A
Rationale: The correct answer is A: Hyporeflexia. In a patient with a herniated intervertebral disk, compression of the spinal nerve can lead to decreased reflexes (hyporeflexia) due to nerve root involvement. This is because the nerve transmission is impaired, resulting in decreased reflex responses. Increased muscle tone (B) is less likely as the herniation typically leads to muscle weakness or atrophy. Positive Babinski sign (C) and presence of pathologic reflexes (D) are associated with upper motor neuron lesions, not typically seen in herniated disk cases.
Question 5 of 5
A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying 'I'm just getting old!' After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C. Misplacing items, such as putting dish soap in the refrigerator, is indicative of Alzheimer's disease as it reflects difficulties with executive functioning and memory. This behavior goes beyond occasional forgetfulness (choice A) and having trouble finding the right word (choice D). Difficulty performing familiar tasks (choice B) can also be a sign of Alzheimer's, but misplacing items is more specific to memory and executive function impairment. In this case, the patient's behavior suggests a pattern of cognitive decline rather than just normal aging.