ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
A child diagnosed with autism spectrum disorder makes no eye contact, does not respond to verbal directions from the staff members, and constantly twists, spins, and headbangs. Which of the following would be the best nursing action?
Correct Answer: B
Rationale: The correct answer is B. Ensuring the child does not receive an injury from body movements is the best nursing action because safety is the top priority when dealing with a child exhibiting self-injurious behaviors like headbanging and spinning. By preventing injuries, the child's well-being is prioritized. Choice A is incorrect because instructing the child to follow directions may not be effective if the child is non-responsive due to their autism spectrum disorder. Choice C is incorrect as placing the child in seclusion is not recommended for managing behaviors related to autism spectrum disorder. It does not address the underlying cause and can lead to further distress. Choice D is incorrect as showing the child how to maintain eye contact may not be feasible or effective at that moment, especially if the child is exhibiting self-injurious behaviors.
Question 2 of 5
A client states she is hearing voices that tell her to cut herself. She already has several superficial marks on her wrists from scratching herself with the plastic eating utensils. She will not contract for safety. What is the priority nursing intervention?
Correct Answer: C
Rationale: The correct answer is C: Place on one-on-one, constant observation to ensure she does not harm herself. This is the priority nursing intervention because the client is at high risk for self-harm, as evidenced by hearing voices telling her to cut herself and already having marks on her wrists. Since she will not contract for safety, one-on-one observation is necessary to prevent harm. Removing plastic utensils (choice A) may not be sufficient to prevent self-harm. Conducting 15-minute checks (choice B) is not appropriate given the level of risk. Seclusion (choice D) is a restrictive intervention and should only be used as a last resort when less restrictive measures are insufficient. Constant observation ensures immediate intervention if self-harm is attempted, making it the most appropriate intervention in this scenario.
Question 3 of 5
A client is diagnosed with terminal cancer. Which situation should the nurse assess as reflecting Kubler-Ross's grief state of anger?
Correct Answer: A
Rationale: The correct answer is A because the client's statement of feeling that his faith has failed him and refusal to attend church indicate anger, which is a stage of grief according to Kubler-Ross. The client is expressing frustration and resentment towards his faith. Choice B reflects acceptance and preparation for death, not anger. Choice C shows a coping mechanism of setting a future goal, which is a form of denial or bargaining, not anger. Choice D reflects bargaining with God, which is another stage of grief, not anger. In summary, the other choices do not specifically demonstrate anger as a grief state according to Kubler-Ross, making choice A the correct answer.
Question 4 of 5
A client has been given a diagnosis of human immunodeficiency virus (HIV). Which statement made by the client does the nurse recognize as the bargaining stage of grief?
Correct Answer: B
Rationale: The correct answer is B: "If I don't do intravenous (IV) drugs anymore, God won't let me die." This statement reflects the bargaining stage of grief, where the individual tries to negotiate with a higher power to avoid the negative outcome. It shows a sense of trying to control the situation through a specific action. In contrast, choices A, C, and D do not demonstrate bargaining behavior. Choice A expresses anger and blame, not bargaining. Choice C shows acceptance and proactive behavior, not bargaining. Choice D reflects denial or disbelief in the diagnosis, not bargaining.
Question 5 of 5
A client who is being treated for chronic kidney disease complains to the health-care provider that he does not like the food available to him while hospitalized. The health-care provider insists that the client strictly adhere to the diet plan. What action can be expected if the client uses the defense mechanism of displacement?
Correct Answer: C
Rationale: The correct answer is C: The client snaps at the nurse and criticizes the nursing care provided. Displacement is a defense mechanism where emotions are redirected from the original source to a less threatening target. In this case, the client's frustration towards the healthcare provider's diet plan is displaced onto the nurse, leading to snapping and criticizing the nursing care. This behavior allows the client to express their anger indirectly. Incorrect choices: A: The client assertively confronts the health-care provider. This is not an example of displacement; it is direct confrontation. B: The client insists on being discharged and goes for a long, brisk walk. This choice does not demonstrate displacement but rather avoidance of the situation. D: The client hides his anger by explaining the logical reasoning for the diet to his spouse. This choice does not involve displacement but rather rationalizing the situation to cope with anger.