ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?
Correct Answer: A
Rationale: The correct answer is A: Allow the client to rest and sleep. This is the most important action because sleep deprivation can exacerbate feelings of sadness and depression. By prioritizing rest and sleep within the first 24 hours, the nurse can address the immediate physical and emotional needs of the client. This action can help improve the client's overall well-being and mental health. Choices B, C, and D are incorrect: - B: Ensuring the client attends groups addressing coping skills for dealing with depression is important but not the most critical within the first 24 hours. Rest and sleep should be prioritized initially. - C: Planning for the client's discharge is premature and not a priority when the client is in immediate distress. - D: Encouraging verbalization of feelings is important for therapeutic communication but addressing sleep deprivation takes precedence in this scenario.
Question 2 of 5
An 18-year-old client is brought to the emergency department with a suspected overdose. Which information is most important for the nurse to obtain from the family?
Correct Answer: A
Rationale: The correct answer is A: The drug that was ingested. This information is crucial for determining the appropriate treatment and antidote for the overdose. Knowing the specific substance helps the healthcare team assess the severity of the overdose and provide targeted care. Explanation of why the other choices are incorrect: - B: The time of ingestion is important but not as critical as knowing the specific drug for immediate intervention. - C: The client's medical history is relevant but not as urgent as identifying the ingested substance for immediate treatment. - D: The client's mental health history is important for long-term care but not as vital as identifying the drug for immediate life-saving measures.
Question 3 of 5
A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
Correct Answer: A
Rationale: The correct answer is A: Provide a structured environment with little stimuli. In the manic phase of bipolar disorder, clients often exhibit increased energy, agitation, and impulsivity. A structured environment with minimal stimuli helps reduce overstimulation and provides a sense of predictability, promoting a sense of safety and stability. This intervention can help prevent escalation of manic symptoms and promote self-regulation. Summary: B: Encouraging group activities may overstimulate the client and exacerbate manic symptoms. C: Allowing the client to set her own schedule may lead to erratic behavior and lack of boundaries. D: Administering sedative medications should be a last resort and not the initial intervention for managing manic symptoms.
Question 4 of 5
Patient with alcoholic withdrawal symptoms who says she has snakes all over her body. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer PRN Lorazepam (Ativan). This is because the patient is experiencing hallucinations, a common symptom of alcohol withdrawal. Lorazepam is a benzodiazepine that can help reduce anxiety and manage hallucinations effectively in this situation. Providing a quiet environment (B) may be helpful, but addressing the hallucinations is the priority. Offering fluids and snacks (C) and reassuring the client (D) do not directly address the underlying issue of hallucinations and may not provide adequate relief for the patient's distress.
Question 5 of 5
A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Small amount of effort to solve the problem. This strategy is appropriate because it focuses on breaking down tasks into smaller, more manageable steps, which can help the client with depression feel less overwhelmed and more motivated to address personal hygiene and responsibilities. By taking small steps, the client can experience a sense of accomplishment and gradually increase their engagement in self-care activities. Option B: Encouraging the client to set daily goals may be overwhelming for someone with depression and may not address the underlying issues causing the lack of motivation. Option C: Providing opportunities for social interaction is important for overall well-being, but it may not directly address the client's specific coping needs related to personal hygiene and lack of enjoyment in activities. Option D: Teaching relaxation techniques can be helpful for managing stress and anxiety, but it may not directly address the client's lack of motivation and engagement in self-care activities.