ATI RN
Psychiatry Test Bank Questions
Question 1 of 5
A patient tries to gouge out their eye in response to auditory hallucinations. The nurse would analyze this behavior as indicating:
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Impaired impulse control. Impaired impulse control refers to the inability to resist or control impulsive behaviors. In the case described, the patient's action of trying to gouge out their eye in response to auditory hallucinations demonstrates a significant lack of control over their impulses. Option A) Derealization is not the correct answer because derealization refers to feeling detached from one's surroundings, which is not the behavior exhibited by the patient in the question. Option B) Inappropriate affect is also incorrect as it refers to emotions that are not suitable for the circumstances, rather than impulsive behavior like attempting self-harm. Option D) Inability to manage anger is not the best choice because the behavior described is more indicative of impulse control issues rather than solely anger management problems. From an educational standpoint, understanding the concept of impaired impulse control is crucial in psychiatric nursing as it helps nurses recognize and respond to behaviors that may pose a risk to the patient or others. By differentiating between various psychiatric symptoms and behaviors, nurses can provide appropriate care and interventions to ensure patient safety and well-being.
Question 2 of 5
Immediately after electroconvulsive therapy, in which position should a nurse place the client?
Correct Answer: A
Rationale: In the context of post-electroconvulsive therapy (ECT), it is crucial for the nurse to place the client on his or her side (Option A) to prevent aspiration. As ECT can induce confusion, disorientation, and muscle weakness immediately after the procedure, there is a risk of regurgitation and aspiration if the client is lying flat on their back. Placing the client on their side helps to ensure that any vomitus or secretions can easily drain out of the mouth, reducing the risk of aspiration pneumonia and other respiratory complications. Option B, placing the client in semi-Fowler's position to promote oxygenation, is incorrect in this scenario because the priority post-ECT is to prevent aspiration rather than focusing solely on oxygenation. Placing the client in Trendelenburg's position (Option C) could actually be harmful as it may increase intracranial pressure and is not indicated for this situation. Option D, placing the client in a prone position to prevent airway blockage, is also incorrect as lying prone could further increase the risk of aspiration. In an educational context, understanding the rationale behind positioning post-ECT is essential for nurses working in psychiatric settings. It not only ensures the safety and well-being of the client but also demonstrates the nurse's knowledge of proper post-procedural care. By prioritizing the prevention of aspiration in this scenario, nurses can provide effective and evidence-based care to clients undergoing ECT.
Question 3 of 5
Which assessment finding should be considered a high risk factor for adolescent suicide?
Correct Answer: A
Rationale: In the context of adolescent suicide risk assessment, option A, being sexually abused, is considered a high-risk factor for several reasons. Adolescents who have experienced sexual abuse may suffer from various psychological traumas, such as depression, anxiety, and post-traumatic stress disorder, which significantly increase their vulnerability to suicidal ideation and behavior. Options B, having experienced panic attacks, and C, being mildly cognitively impaired, while important factors to consider in a comprehensive psychiatric assessment, do not directly correlate with as high a risk of suicide in adolescents as a history of sexual abuse does. Panic attacks and cognitive impairments can contribute to mental health challenges but do not carry the same level of immediate risk as a history of sexual abuse. Option D, having a diagnosis of type 1 diabetes, is also a relevant factor to consider in the overall assessment of an adolescent's mental health and well-being. However, it is not typically considered as high a risk factor for suicide as a history of sexual abuse, which is more directly linked to mental health issues and suicidal behavior in adolescents. In an educational context, it is crucial for healthcare providers, particularly those in psychiatry or mental health fields, to be able to recognize and prioritize risk factors for adolescent suicide accurately. Understanding the significance of different risk factors can help in conducting thorough assessments, developing appropriate interventions, and implementing preventive strategies to support at-risk adolescents effectively.
Question 4 of 5
Which statement made by a teenage male hospitalized after a failed suicide attempt is most concerning to the nurse?
Correct Answer: D
Rationale: In this scenario, option D, "The gun I got for my birthday is my most prized possession," is the most concerning statement made by the teenage male hospitalized after a failed suicide attempt. This statement raises red flags because it indicates that the individual may still have access to a potentially lethal means of self-harm, which increases the risk of a repeated suicide attempt. Option A is incorrect because it repeats the same statement as option D. Option B, "I don’t know why I get so depressed and want to die," while concerning, reflects a sense of confusion rather than immediate danger. Option C, "I don’t feel like I can talk to anyone about my feelings," is also worrying but does not pose an immediate threat to the individual's safety. Educationally, this question highlights the importance of assessing suicide risk factors, such as access to lethal means, in individuals who have attempted suicide. It emphasizes the critical role nurses play in identifying and addressing potential risks to ensure the safety and well-being of patients experiencing psychiatric crises. By understanding the significance of statements like the one in option D, healthcare providers can intervene effectively to prevent further harm and provide appropriate support and interventions.
Question 5 of 5
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient?
Correct Answer: A
Rationale: In this scenario, the correct nursing diagnosis is A) Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at an increased risk for suicidal ideation or behavior. The nurse must assess this risk to ensure the patient's safety. Option B) Anxiety related to sudden and abrupt lifestyle changes may be present, but it is not the priority in this case as the patient's risk for suicide takes precedence. Option C) Social isolation related to loss of existing family is a valid concern, but it is not as urgent as the risk for suicide, which requires immediate attention. Option D) Spiritual distress related to anger with God is important to address but is not the priority when the patient's life is at risk. In an educational context, this question highlights the importance of prioritizing nursing interventions based on the level of risk to the patient. Understanding how to identify and address immediate life-threatening concerns is crucial in psychiatric nursing practice. It emphasizes the need for thorough assessment and critical thinking to provide safe and effective care to patients in vulnerable situations.