ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
An 18-year-old client is brought to the emergency department with a suspected overdose. Which information is most important for the nurse to obtain from the family?
Correct Answer: A
Rationale: The correct answer is A: The drug that was ingested. This information is crucial for determining the appropriate treatment and antidote for the overdose. Knowing the specific substance helps the healthcare team assess the severity of the overdose and provide targeted care. Explanation of why the other choices are incorrect: - B: The time of ingestion is important but not as critical as knowing the specific drug for immediate intervention. - C: The client's medical history is relevant but not as urgent as identifying the ingested substance for immediate treatment. - D: The client's mental health history is important for long-term care but not as vital as identifying the drug for immediate life-saving measures.
Question 2 of 5
Patient with alcoholic withdrawal symptoms who says she has snakes all over her body. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer PRN Lorazepam (Ativan). This is because the patient is experiencing hallucinations, a common symptom of alcohol withdrawal. Lorazepam is a benzodiazepine that can help reduce anxiety and manage hallucinations effectively in this situation. Providing a quiet environment (B) may be helpful, but addressing the hallucinations is the priority. Offering fluids and snacks (C) and reassuring the client (D) do not directly address the underlying issue of hallucinations and may not provide adequate relief for the patient's distress.
Question 3 of 5
A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Small amount of effort to solve the problem. This strategy is appropriate because it focuses on breaking down tasks into smaller, more manageable steps, which can help the client with depression feel less overwhelmed and more motivated to address personal hygiene and responsibilities. By taking small steps, the client can experience a sense of accomplishment and gradually increase their engagement in self-care activities. Option B: Encouraging the client to set daily goals may be overwhelming for someone with depression and may not address the underlying issues causing the lack of motivation. Option C: Providing opportunities for social interaction is important for overall well-being, but it may not directly address the client's specific coping needs related to personal hygiene and lack of enjoyment in activities. Option D: Teaching relaxation techniques can be helpful for managing stress and anxiety, but it may not directly address the client's lack of motivation and engagement in self-care activities.
Question 4 of 5
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone. When the client walks to the nurse station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed anticholinergic Benztropine (Cogentin) for dystonia. In this scenario, the client's presentation of walking in a laterally contracted position and attributing it to something external causing his body to contort into a monster is indicative of acute dystonia, a side effect of antipsychotic medications like Risperidone. Administering Benztropine, an anticholinergic medication, helps alleviate dystonic symptoms by blocking the effects of excess acetylcholine in the brain. It is important to address dystonic symptoms promptly to prevent further distress and potential complications. Incorrect choices: B: Reassuring the client that the sensation is temporary does not address the underlying cause of the symptoms and may lead to increased distress. C: Encouraging the client to relax and breathe deeply may not effectively manage the acute dystonic symptoms and could delay proper treatment. D: While documenting the client's symptoms and notifying
Question 5 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.