ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
An adult in the emergency department states, 'Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind.' Vital signs are slightly elevated. The nurse should suspect
Correct Answer: B
Rationale: The correct answer is B: hallucinogen ingestion. The individual's symptoms of visual distortions, feelings of detachment from reality, and paranoia are indicative of a hallucinogenic experience. Hallucinogens such as LSD or mushrooms can cause these perceptual disturbances. Vital signs being slightly elevated can also be a sign of hallucinogen use. Schizophrenic episodes (A) typically involve more persistent and complex symptoms over time. Opium intoxication (C) would present with different symptoms such as drowsiness and respiratory depression. Cocaine overdose (D) would exhibit symptoms like agitation, chest pain, and hypertension.
Question 2 of 5
The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is
Correct Answer: A
Rationale: The correct answer is A: hopelessness. Hopelessness is a key predictor of elevated suicide risk as it reflects a sense of despair and lack of belief in positive outcomes. Patients who feel hopeless may be more likely to consider suicide as a way to escape their perceived unending suffering. In contrast, sadness (B) is a common emotion that may not necessarily indicate an immediate suicide risk. Elation (C) is also not indicative of suicide risk, as individuals experiencing high levels of joy are less likely to consider suicide. Anger (D) may be a sign of distress but is not as strongly associated with suicide risk as hopelessness.
Question 3 of 5
Which individual in the emergency department should be considered at highest risk for completing suicide?
Correct Answer: D
Rationale: The correct answer is D because the 79-year-old single, white male diagnosed with terminal cancer of the prostate is at the highest risk for completing suicide. This individual is facing a terminal illness, which can lead to feelings of hopelessness and despair, increasing the risk of suicide. The other choices do not present such high-risk factors for suicide. A: While the adolescent Asian American girl may face pressures from high achievements and asthma, these factors do not inherently place her at the highest risk for suicide. B: The 38-year-old single, African American female church member with fibrocystic breast disease may face challenges, but they do not indicate a high risk for suicide. C: The 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes has family support and does not have as severe risk factors as the individual in choice D.
Question 4 of 5
A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action?
Correct Answer: D
Rationale: The correct answer is D because the patient's action of hitting the UAP is likely due to a misinterpretation of the situation as potentially harmful. The patient was asleep and abruptly awakened by a touch, leading to a defensive response. This is a common reaction in situations where individuals feel threatened or startled. The other choices are incorrect because A is a generalization without specific relevance to this scenario, B is not supported by evidence in the question stem, and C assumes the patient learned violent behavior from others, which is not indicated in the scenario.
Question 5 of 5
After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, 'That patient should not be allowed to get away with that behavior.' Which response poses the greatest barrier to the nurse's ability to provide therapeutic care?
Correct Answer: C
Rationale: The correct answer is C because harboring a wish for revenge can significantly impede a nurse's ability to provide therapeutic care. This response indicates unresolved anger and potential desire for retaliation, which can lead to compromised objectivity, empathy, and professionalism in patient care. It can also hinder the development of a therapeutic nurse-patient relationship. Startle reactions (A), difficulty sleeping (B), and preoccupation with the incident (D) are common responses to trauma but do not pose as significant a barrier as a wish for revenge.