ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the RN?
Correct Answer: A
Rationale: The correct answer is A because attempting to physically restrain the client can escalate the situation and potentially harm the client or the mental health worker. Restraints should only be used as a last resort and under the guidance of a healthcare professional. Choice B is not ideal as it may not effectively de-escalate the situation. Choice C may further agitate the client. Choice D is not the most critical concern at the moment compared to physical restraint.
Question 2 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 3 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 4 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.
Question 5 of 5
Patient with schizophrenia enters the psychiatric unit with symptoms. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the medication list. This is crucial as patients with schizophrenia often take antipsychotic medications that help manage their symptoms. Checking the medication list ensures the patient is receiving the appropriate treatment and dosage. Assessing for signs of infection (B) and monitoring vital signs (C) are important but not the priority in this case. Providing a quiet environment (D) is beneficial for patients with schizophrenia, but checking the medication list takes precedence to ensure proper treatment.