ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone. When the client walks to the nurse station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed anticholinergic Benztropine (Cogentin) for dystonia. In this scenario, the client's presentation of walking in a laterally contracted position and attributing it to something external causing his body to contort into a monster is indicative of acute dystonia, a side effect of antipsychotic medications like Risperidone. Administering Benztropine, an anticholinergic medication, helps alleviate dystonic symptoms by blocking the effects of excess acetylcholine in the brain. It is important to address dystonic symptoms promptly to prevent further distress and potential complications. Incorrect choices: B: Reassuring the client that the sensation is temporary does not address the underlying cause of the symptoms and may lead to increased distress. C: Encouraging the client to relax and breathe deeply may not effectively manage the acute dystonic symptoms and could delay proper treatment. D: While documenting the client's symptoms and notifying
Question 2 of 5
Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing action?
Correct Answer: A
Rationale: The correct answer is A because safety of other clients is the priority. Moving other clients to another room ensures their well-being and respects their privacy. Administering sedative medication (B) should be a last resort and requires consent. Confronting the client (C) may escalate the situation. Ignoring the behavior (D) neglects duty of care.
Question 3 of 5
The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms the assessment?
Correct Answer: A
Rationale: The correct answer is A because it reflects a paranoid delusion where the client believes the nurse is trying to harm him. This statement confirms the client's distorted perception of reality, a common feature of paranoid schizophrenia. Option B shows denial of illness, not delusional thinking. Option C involves persecution delusion but does not confirm the assessment. Option D indicates auditory hallucinations, not delusions. Therefore, A is the correct choice as it directly aligns with the client's paranoid delusional beliefs.
Question 4 of 5
A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the nurse include to ensure the client is physiologically stable?
Correct Answer: A
Rationale: The correct answer is A: Monitor vital signs. This is crucial in managing a client with delirium tremens to ensure physiological stability. Monitoring vital signs such as blood pressure, heart rate, temperature, and respiratory rate can help identify any signs of deterioration or complications like dehydration, sepsis, or cardiovascular instability. By closely monitoring these parameters, the nurse can intervene promptly and prevent any further complications. Summary: - Option B is incorrect because administering antipsychotic medication is not the priority in managing delirium tremens. - Option C is incorrect as providing a quiet environment may help with managing hallucinations, but it does not address the physiological stability of the client. - Option D is incorrect as encouraging fluid intake is important for hydration but does not address the need for monitoring vital signs to ensure physiological stability.
Question 5 of 5
The nurse goes to answer a call light, and the patient is aggressive and agitated. What is most important for the nurse to do?
Correct Answer: A
Rationale: The correct answer is A: Stay in the doorway. By staying in the doorway, the nurse maintains a safe distance from the aggressive and agitated patient, reducing the risk of harm to both the nurse and the patient. Approaching calmly (B) may escalate the situation. Administering sedative medication (C) without assessing the situation further can be dangerous. Calling for additional staff assistance (D) is important, but the immediate priority is ensuring safety by staying in a safer position.