ATI RN
Target Healthcare Questions
Question 1 of 5
A depressed patient is receiving imipramine (Tofranil) 300 mg daily. Which side effect requires seeking medical attention?
Correct Answer: D
Rationale: The correct answer is D: Urinary retention. Imipramine is known to cause anticholinergic side effects, such as urinary retention. This side effect is serious and requires immediate medical attention to prevent complications like bladder distention or urinary tract infections. Dry mouth and blurred vision are common but less urgent side effects of imipramine, while nasal congestion is not typically associated with this medication. Thus, urinary retention stands out as the side effect requiring immediate medical attention among the choices provided.
Question 2 of 5
Which nursing diagnosis is a priority for both a patient with depression and one with acute mania?
Correct Answer: B
Rationale: The correct answer is B: Disturbed sleep pattern. Both depression and acute mania can disrupt sleep, leading to negative impacts on overall health. Sleep disturbances can exacerbate symptoms of both conditions and hinder recovery. Addressing sleep patterns is crucial in managing symptoms and improving outcomes for patients with depression and acute mania. A: Deficient diversional activity is more relevant to depression than acute mania, as patients with mania often engage in excessive activities. C: Fluid volume excess is not typically associated with depression or acute mania. D: Defensive coping may be relevant to both conditions but is not a priority compared to addressing sleep patterns for patient safety and symptom management.
Question 3 of 5
A client tried to gouge out his eye in response to auditory hallucinations commanding, 'If thine eye offend thee, pluck it out.' The nurse would analyze this behavior as indicating:
Correct Answer: A
Rationale: The correct answer is A: Impaired impulse control. This behavior shows a lack of control over impulsive actions, as the client acted immediately on the auditory hallucination without considering the consequences. Choice B is incorrect because anger management is not directly related here. Choice C, derealization, refers to feeling disconnected from reality, which is not evident in the scenario. Choice D, inappropriate affect, does not fit as the client's action is more about impulsivity than emotional expression. Ultimately, the client's behavior aligns most closely with impaired impulse control due to the immediate and extreme response to the auditory hallucination.
Question 4 of 5
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (SHT2) excess will suggest that the client receive:
Correct Answer: C
Rationale: Rationale: Olanzapine (Zyprexa) is the correct choice because it is an atypical antipsychotic that targets serotonin receptors, particularly 5-HT2 receptors known to be involved in negative symptoms of schizophrenia like apathy, avolition, and blunted affect. Olanzapine's mechanism of action helps alleviate these symptoms by modulating serotonin levels in the brain. Incorrect Choices: A: Haloperidol and B: Chlorpromazine are typical antipsychotics that primarily target dopamine receptors and are less effective in treating negative symptoms associated with schizophrenia. D: Phenelzine is a monoamine oxidase inhibitor used to treat depression and anxiety disorders, not schizophrenia symptoms related to serotonin excess.
Question 5 of 5
A client tells the nurse, 'I hear people whispering about me. When I'm in the day room and they do that, I want to punch them.' The information the nurse should give to staff in report consists of which of the following?
Correct Answer: A
Rationale: The correct answer is A: "Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence." This response is appropriate because it emphasizes the importance of respecting the client's privacy and dignity by not discussing him or others in his presence. By being direct and matter-of-fact, the nurse can establish trust and build a therapeutic relationship with the client. This approach also helps maintain boundaries and avoids escalating the situation. Choice B is incorrect because avoiding the client may lead to feelings of rejection and worsen his symptoms. Choice C is incorrect because using touch without the client's consent may be inappropriate and could escalate the situation. Choice D is incorrect because speaking softly does not address the underlying issue of the client feeling threatened by whispering.