ATI RN
Multiple Choice Questions on Psychiatric Emergencies Questions
Question 1 of 5
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle accident. The nurse includes in the plan of care to observe for signs of delirium tremens. Which early signs indicate that the client is beginning to have delirium tremens?
Correct Answer: A
Rationale: The correct answer is A: Restlessness and confusion. Delirium tremens (DT) is a severe form of alcohol withdrawal that can occur in individuals with a history of alcohol abuse. Early signs of DT include restlessness and confusion. This is due to the sudden cessation of alcohol intake, leading to overactivity of the central nervous system. Lethargy and bradycardia (choice B) are not typical signs of DT, as DT is characterized by hyperactivity of the CNS. Euphoria and hyperactivity (choice C) are also not indicative of DT, as DT is associated with agitation and confusion. Fever and seizures (choice D) can occur in severe cases of DT, but they are not typically early signs. Therefore, choice A is the correct answer as restlessness and confusion are early signs of delirium tremens.
Question 2 of 5
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?
Correct Answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own anger and selfishness onto his roommate. By attributing these negative traits to someone else, the client avoids acknowledging and dealing with his own feelings. This defense mechanism helps protect his self-image and cope with uncomfortable emotions. Denial (A) involves refusing to accept reality, rationalization (C) involves justifying behavior with logical excuses, and splitting (D) involves seeing people as all good or all bad, which are not demonstrated in the scenario.
Question 3 of 5
While sitting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique?
Correct Answer: C
Rationale: The correct answer is C: Allow the client to identify the way he interacts. By demonstrating the client's behaviors, the RN is providing a mirror for the client to see how he interacts with others. This technique helps the client gain insight into his own behaviors and communication style. It can facilitate self-awareness and promote reflection on the impact of his actions on others. Options A, B, and D do not focus on the client's self-awareness and identification of his behaviors, making them incorrect choices. Option A focuses on initiating conversation, option B on dialogue about ineffectiveness, and option D on discussing feelings, but they do not directly address the goal of allowing the client to identify his interactions.
Question 4 of 5
A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about
Correct Answer: C
Rationale: Step 1: SSRIs can initially increase suicidal thoughts in some patients due to changes in neurotransmitter levels. Step 2: Monitoring for increased suicidal thoughts is crucial to prevent harm. Step 3: Reporting increased suicidal thoughts allows for timely intervention and adjustment of treatment. Step 4: Choices A, B, and D are irrelevant to SSRI therapy for depressive disorder.
Question 5 of 5
Major depressive disorder resulted after a patient's employment was terminated. The patient now says to the nurse, 'I'm not worth the time you spend with me. I am the most useless person in the world.' Which nursing diagnosis applies?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Situational low self-esteem. This is because the patient's negative self-perception and feelings of worthlessness are directly related to the situational trigger of losing their job. This diagnosis captures the temporary nature of the self-esteem issue. A: Powerlessness does not fully capture the patient's self-esteem issues. B: Defensive coping is not the most appropriate diagnosis as the patient is not exhibiting defensive behaviors. D: Disturbed personal identity is not the best fit as the patient's issue is more focused on self-worth rather than identity confusion or alteration.