ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?
Correct Answer: C
Rationale: The correct answer is C because addressing the client's refusal to address nutritional needs is the top priority. This is crucial for physical health and recovery from depression. Neglecting nutrition can lead to further physical and mental health deterioration. Loss of interest in diversional activity (A) and low self-esteem (D) are important but addressing basic needs like nutrition takes precedence. Social isolation (B) is also significant, but ensuring proper nutrition is more urgent for immediate well-being.
Question 2 of 5
A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?
Correct Answer: D
Rationale: The correct answer is D: Delusions of persecution. The client's behavior of being guarded, isolating, and peeking into the hall suggests paranoia and fear of being persecuted. This aligns with delusions of persecution, a common symptom seen in clients with mental health conditions like schizophrenia. Visual hallucinations (A) and auditory hallucinations (B) typically involve seeing or hearing things that are not there, which are not evident in the scenario. Excessive motor activity (C) does not fit the client's observed behavior of isolating in the room. Delusions of grandeur are not mentioned in the scenario, making option D the most suitable choice.
Question 3 of 5
A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
Correct Answer: B
Rationale: The correct answer is B: Wishing to be with the deceased spouse. This statement indicates a desire for death or suicidal ideation, which is a critical concern that requires immediate exploration and intervention. The client may be at risk for self-harm or suicide. It is essential for the RN to assess the severity of this statement and ensure the client's safety. A: Not sleeping for several days - While important, this symptom may be related to grief and depression. However, it is not as urgent as assessing for suicidal ideation. C: Lack of interest in usual activities - Common in grief and depression, but does not indicate immediate risk of harm. D: Eating very little - Also common in grief, but not as urgent as assessing for suicidal ideation.
Question 4 of 5
An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
Correct Answer: D
Rationale: The correct answer is D: Assist the client to clean the walls. This action promotes therapeutic communication, maintains dignity, and encourages self-care. It allows the client to take responsibility for their actions and fosters a sense of autonomy. Choices A and B may be condescending and fail to address the behavior directly. Choice C may escalate the situation and jeopardize the therapeutic relationship.
Question 5 of 5
A client is admitted to the mental health unit and sits in the corner of the dayroom. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
Correct Answer: A
Rationale: The correct action for the nurse to implement is to attempt to ask the client simple questions (Choice A). By asking simple questions, the nurse can start building rapport with the client and gradually gain their trust. This approach can help the client feel more comfortable and open up during the assessment interview. It is important for the nurse to demonstrate patience, empathy, and understanding towards the client's guarded and suspicious behavior. Postponing the client interview until the next day (Choice B) may not address the client's current needs and may lead to further distrust. Asking another nurse to talk with the client (Choice C) may not necessarily be effective as the client may benefit from continuity of care with the same nurse. Documenting the client's paranoid behavior (Choice D) is important for the client's medical record but should not be the only action taken by the nurse in this situation.