ATI RN
Use of Psychotropic Medications Questions
Question 1 of 5
A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?
Correct Answer: C
Rationale: The correct answer is C because the sensory cortex does not have the ability to localize pain in the heart. When the heart lacks oxygen, pain signals are perceived in other areas like the chest, shoulder, arms, or jaw due to a phenomenon called referred pain. The heart and these other areas share nerve pathways, leading to the brain interpreting the pain as originating from these other regions. Choices A, B, and D are incorrect because they do not address the specific mechanism of referred pain and the role of the sensory cortex in interpreting pain signals from different parts of the body.
Question 2 of 5
During the neurologic assessment of a 'healthy' 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
Correct Answer: B
Rationale: The correct answer is B: Mild, even resistance to movement. In a healthy individual, when asked to relax muscles completely, there should be mild, even resistance to movement as the nurse moves each extremity through full range of motion. This signifies normal muscle tone and functioning. A: Firm, rigid resistance to movement would indicate increased muscle tone or spasticity, which is not expected in a healthy individual. C: Hypotonic muscles would be flaccid and weak, which is not expected in a relaxed healthy individual. D: Slight pain with movement is not a normal finding during a neurologic assessment in a healthy individual.
Question 3 of 5
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to:
Correct Answer: A
Rationale: The correct answer is A because asking the patient to lock her fingers and pull engages the upper motor neurons, potentially facilitating the reflex response. This technique, known as Jendrassik maneuver, can help in eliciting reflexes that were initially absent. It is important to try this before proceeding with further testing or documenting reflexes as 0. Choice B is incorrect as retesting immediately after the maneuver may yield a different result. Choice C is premature as further testing may not be necessary after trying the Jendrassik maneuver. Choice D is incorrect as documenting reflexes as 0 without attempting the Jendrassik maneuver could lead to an inaccurate assessment.
Question 4 of 5
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):
Correct Answer: D
Rationale: The correct answer is D: Decreased level of consciousness. The patient's confusion about his age and location after a head injury indicates disorientation, a classic sign of altered mental status. This is likely due to the head injury affecting his brain function, leading to impaired cognitive abilities. This finding raises concern for decreased level of consciousness, as the patient is unable to accurately perceive his age or location. Summary: A: Great sense of humor - This choice is incorrect as the patient's response is not a deliberate attempt at humor. B: Uncooperative behavior - This choice is incorrect as the patient's response is not indicative of intentional noncompliance. C: Inability to understand questions - This choice is incorrect as the patient's response suggests more than just a simple misunderstanding of questions.
Question 5 of 5
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?
Correct Answer: A
Rationale: The correct answer is A: Hyporeflexia. In a patient with a herniated intervertebral disk, compression of the spinal nerve can lead to decreased reflexes (hyporeflexia) due to nerve root involvement. This is because the nerve transmission is impaired, resulting in decreased reflex responses. Increased muscle tone (B) is less likely as the herniation typically leads to muscle weakness or atrophy. Positive Babinski sign (C) and presence of pathologic reflexes (D) are associated with upper motor neuron lesions, not typically seen in herniated disk cases.