ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
A patient tells the nurse that he is going to kill his sister. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Notify the healthcare provider. This is the appropriate action because the patient's statement indicates a serious threat to someone's life, requiring immediate intervention by a higher authority for safety measures. Confronting the patient directly may escalate the situation. Administering sedatives is not appropriate as it does not address the threat. Documenting the statement is important but should not be the first and only action taken in such a critical situation.
Question 2 of 5
Following involvement in a MVC, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
Correct Answer: D
Rationale: The correct answer is D, Lorazepam (Ativan) 2 mg IM. This is because delirium tremens (DTs) is a severe form of alcohol withdrawal that can be life-threatening. Lorazepam is a benzodiazepine that helps to manage the symptoms of alcohol withdrawal, including agitation, hallucinations, and seizures. It works by calming the central nervous system. Prochlorperazine (A) is an antiemetic, not suitable for managing DTs. Hydromorphone (B) is an opioid analgesic, not indicated for alcohol withdrawal. Chlorpromazine (C) is an antipsychotic used for conditions like schizophrenia, not for alcohol withdrawal. In summary, Lorazepam is the appropriate choice for managing DTs due to its effectiveness in calming the central nervous system and managing alcohol withdrawal symptoms.
Question 3 of 5
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Priority is given to airway and breathing concerns for immediate stabilization. Impaired comfort (A) is important but not life-threatening. Risk for injury (B) may be a concern, but airway takes precedence. Ineffective coping (D) is significant for long-term care but not immediate priority.
Question 4 of 5
A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient
Correct Answer: D
Rationale: The correct answer is D because conferring with a pharmacist when selecting over-the-counter medications is crucial when taking phenelzine. This is because phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with various over-the-counter medications, leading to potentially dangerous side effects such as serotonin syndrome. Monitoring sodium intake and weight (choice A) is important for other medications but not specifically for phenelzine. Wearing support stockings and elevating legs (choice B) is not directly related to phenelzine. Identifying foods with high selenium content (choice C) is not relevant as phenelzine does not interact with selenium.
Question 5 of 5
Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective?
Correct Answer: A
Rationale: The correct answer is A because it indicates positive outcomes in the patient's mood and behavior. Sleeping 6 hours uninterrupted suggests improved sleep patterns, singing with an activity group shows engagement and enjoyment, and looking forward to seeing the grandchild demonstrates positive anticipation and social connection. This documentation aligns with the goals of treating major depressive disorder, which include improving sleep, increasing social interaction, and enhancing mood. Choice B is incorrect because the patient's statement about the project being a failure reflects negative self-perception, which is not indicative of treatment effectiveness. Choice C is incorrect because the patient's weight loss and need for assistance with personal hygiene suggest potential ongoing challenges and lack of improvement in self-care. Choice D is incorrect because the patient feeling tired all the time and being preoccupied with inadequacies indicate persistent symptoms of depression and lack of progress in treatment.