ATI RN
Population Specific Care Questions
Question 1 of 5
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
Question 2 of 5
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
Correct Answer: A
Rationale: The correct answer is A: A dystonic reaction"¦administer PRN IM benztropine (Cogentin). This patient is exhibiting symptoms of acute dystonia, a extrapyramidal side effect of haloperidol. Dystonic reactions are characterized by sustained muscle contractions causing abnormal postures. Benztropine is an anticholinergic medication that helps alleviate these symptoms by blocking the neurotransmitter acetylcholine. Administering benztropine is the appropriate treatment for acute dystonia. Summary of other choices: B: Tardive dyskinesia"¦seek a change in the drug or its dosage - Tardive dyskinesia is a side effect that occurs after long-term antipsychotic use, not acutely like in this case. C: Waxy flexibility"¦continue treatment with antipsychotic drugs - Waxy flexibility is a symptom of catatonia, not a side effect of antipsychotic medications
Question 3 of 5
A 32-year-old client with an admitting diagnosis of catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is:
Correct Answer: A
Rationale: The correct answer is A: Risk for deficient fluid volume. The priority nursing diagnosis in this case is to address the client's physical needs to ensure their safety and well-being. The client's mutism and immobility put them at risk for dehydration and malnutrition. By prioritizing the risk for deficient fluid volume, the nurse can address the immediate physiological needs of the client. Choice B: Impaired physical mobility is incorrect because while the client is motionless, the immediate concern is addressing the risk of dehydration. Choice C: Impaired social interaction is incorrect as addressing social interaction is not the priority when the client's physical needs are not being met. Choice D: Ineffective coping is incorrect because the client's presentation is indicative of a more urgent physical need for hydration and nutrition.
Question 4 of 5
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
Correct Answer: B
Rationale: The correct answer is B: Assessing the client for physical problems. This is the initial priority because the client's muteness and motionless state could be due to an underlying physical issue that needs immediate attention, such as dehydration, malnutrition, or infection. By assessing for physical problems first, the nurse can rule out any urgent medical concerns before addressing the client's mental health needs. A: Orienting the client to the unit - While important, this can be done after addressing any physical problems. C: Establishing a nonthreatening relationship - Also essential, but assessing physical health takes precedence. D: Reinforcing reality with the client - Not the immediate priority; physical assessment should come first.
Question 5 of 5
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
Correct Answer: A
Rationale: Step 1: Paranoid schizophrenia is a subtype that tends to have a better prognosis compared to other types. Step 2: The statement that the disorder responds well to treatment and may not recur aligns with the typical course of paranoid schizophrenia. Step 3: With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and have periods of stability. Step 4: Recurrence of symptoms is less likely compared to other types of schizophrenia. Step 5: Therefore, choice A is correct as it provides accurate information about the prognosis of paranoid schizophrenia. Summary: Choice B is incorrect because not all types of schizophrenia are chronic relapsing disorders. Choice C is incorrect as outcomes are not solely determined by prehospital disorganization. Choice D is incorrect as partial remission is not the usual outcome for paranoid schizophrenia.