ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
Client treated with lithium for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
Correct Answer: A
Rationale: Step 1: The symptoms of diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity. Step 2: Nurse should prioritize safety and inform the healthcare provider (HCP) immediately to adjust the treatment plan. Step 3: Delaying the next dose could prevent further toxicity and potential harm to the client. Step 4: Administering an antiemetic or encouraging fluids may not address the underlying issue of lithium toxicity. Step 5: Documenting the symptoms as expected side effects without taking immediate action could lead to serious consequences.
Question 2 of 5
What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks?
Correct Answer: D
Rationale: The correct answer is D because the most crucial goal for a client with major depression on antidepressants is to ensure their safety and prevent self-harm. Monitoring for suicidal ideation and behavior is a top priority. Ventilating feelings of sadness (A) is important but not as critical as ensuring safety. Eating three meals a day (B) and participating in group meetings (C) are important for overall well-being but do not directly address the immediate safety concern of potential suicide attempts.
Question 3 of 5
A highly successful businessman presents to community mental health after complaining of sleepiness and anxiety over his financial status. What should the PN do to diminish his anxiety?
Correct Answer: A
Rationale: The correct answer is A: Teach him to limit sugar and caffeine intake. This is the best option as excessive sugar and caffeine consumption can worsen anxiety symptoms. By reducing intake, it can help stabilize mood and energy levels. Choice B of encouraging a vacation may provide temporary relief but does not address the root cause of anxiety. Choice C of recommending financial counseling focuses solely on the financial aspect, not the physical factors contributing to anxiety. Choice D of administering PRN antianxiety medication should be a last resort and not the initial intervention.
Question 4 of 5
Defense mechanism question: for projection.
Correct Answer: A
Rationale: The correct answer is A because it exemplifies the defense mechanism of projection, where one attributes their unacceptable thoughts or feelings to others. In this case, the individual is shifting blame onto the police for being in the psychiatric facility. Choice B is incorrect as it demonstrates rationalization rather than projection. Choice C is incorrect as it reflects denial rather than projection. Choice D is incorrect as it represents displacement rather than projection.
Question 5 of 5
During one-to-one session with the nurse, a female client who has been admitted for chronic depression and attempted suicide discloses her experience of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, 'I don't remember, but my mother ran my father off when I was five.' The nurse should recognize that the client may be using which defense mechanism?
Correct Answer: A
Rationale: The correct answer is A: Repression. Repression is a defense mechanism where painful or unacceptable memories are pushed into the unconscious mind to avoid conscious awareness. In this scenario, the client's inability to remember potential childhood sexual abuse could be a result of repressing those memories due to the distress they may cause. The client's response of not remembering but mentioning a significant event from childhood (mother running off father) suggests the possibility of repressed memories. Summary: - Choice B: Denial involves refusing to acknowledge reality, which is not evident in this scenario. - Choice C: Projection involves attributing one's own thoughts or feelings to others, which is not applicable in this context. - Choice D: Rationalization involves creating logical explanations to justify behaviors, which is not demonstrated in the client's response.