ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
A client with bulimia and depression who is taking Phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choice should the nurse instruct the client to avoid?
Correct Answer: A
Rationale: The correct answer is A: Pepperoni pizza. Phenelzine is a monoamine oxidase inhibitor (MAOI) which interacts with tyramine-rich foods, like aged, fermented, or spoiled foods, leading to hypertensive crisis. Pepperoni is high in tyramine due to its fermentation process. Grilled chicken salad, steamed vegetables, and fresh fruit are low in tyramine and safe to consume with Phenelzine.
Question 2 of 5
A patient tells the nurse that he is going to kill his sister. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Notify the healthcare provider. This is the appropriate action because the patient's statement indicates a serious threat to someone's life, requiring immediate intervention by a higher authority for safety measures. Confronting the patient directly may escalate the situation. Administering sedatives is not appropriate as it does not address the threat. Documenting the statement is important but should not be the first and only action taken in such a critical situation.
Question 3 of 5
A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. What action does the RN take?
Correct Answer: A
Rationale: The correct answer is A: Pay close attention and document the nonverbal messages. Nonverbal communication can provide valuable insights into a client's true feelings or concerns. By observing and documenting these cues, the RN can gain a better understanding of the client's needs. This approach allows for a more holistic assessment and helps in providing individualized care. Summary: - B: Asking the client's husband to interpret the discrepancy may not be appropriate as it could breach confidentiality and may not provide accurate information. - C: Ignoring the nonverbal behavior can lead to missing important cues affecting the assessment process. - D: Integrating verbal and nonverbal messages is important, but it starts with paying close attention to and documenting nonverbal messages.
Question 4 of 5
Following involvement in a MVC, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
Correct Answer: D
Rationale: The correct answer is D, Lorazepam (Ativan) 2 mg IM. This is because delirium tremens (DTs) is a severe form of alcohol withdrawal that can be life-threatening. Lorazepam is a benzodiazepine that helps to manage the symptoms of alcohol withdrawal, including agitation, hallucinations, and seizures. It works by calming the central nervous system. Prochlorperazine (A) is an antiemetic, not suitable for managing DTs. Hydromorphone (B) is an opioid analgesic, not indicated for alcohol withdrawal. Chlorpromazine (C) is an antipsychotic used for conditions like schizophrenia, not for alcohol withdrawal. In summary, Lorazepam is the appropriate choice for managing DTs due to its effectiveness in calming the central nervous system and managing alcohol withdrawal symptoms.
Question 5 of 5
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Priority is given to airway and breathing concerns for immediate stabilization. Impaired comfort (A) is important but not life-threatening. Risk for injury (B) may be a concern, but airway takes precedence. Ineffective coping (D) is significant for long-term care but not immediate priority.