ATI RN
Health Care Utilization by Age Group Questions
Question 1 of 5
During a manic episode, a patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food and dishes. Verbal intervention is ineffective. The patient's behavior poses a substantial risk of harm to others. Staff escorts the patient to the patient's room to dine alone. What is the rationale for this action?
Correct Answer: B
Rationale: The correct answer is B: Reduce environmental stimuli that negatively affect the patient. This action helps reduce stimulation that may be exacerbating the manic episode, promoting a calmer environment for the patient. Removing the patient from the dining room minimizes triggers for further disruptive behavior. This approach prioritizes the patient's well-being by managing the environmental factors contributing to the escalation of symptoms. A: Preventing other patients from observing the behavior does not directly address the patient's needs during the manic episode and does not actively help in managing the situation. C: Protecting the patient's biological integrity until medication takes effect may be important, but in this scenario, the immediate focus is on addressing the environmental factors contributing to the behavior. D: Reinforcing limit setting is important in managing behavior, but in this specific situation, reducing environmental stimuli is a more immediate and effective intervention.
Question 2 of 5
A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. This is because the client's belief that her thoughts cause earthquakes and the world is burning indicates a break from reality, a hallmark of psychosis in schizophrenia. This demonstrates disorganized and illogical thinking, a key symptom of disturbed thinking. The other choices are incorrect because: A) Altered mood states typically refer to emotional disturbances, which are not the primary deficit in this scenario; C) Social isolation is a consequence of the client's symptoms but not the primary deficit; D) Poor impulse control is not the primary deficit in this case as the client's behavior is more indicative of disorganized thinking.
Question 3 of 5
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will:
Correct Answer: A
Rationale: Step 1: The client is admitted with symptoms suggestive of a psychotic disorder, specifically schizophreniform disorder. Step 2: The admitting diagnosis includes ruling out organic pathology, indicating a need to investigate potential physical causes. Step 3: An MRI test is a non-invasive imaging procedure that can help identify any structural abnormalities in the brain. Step 4: This test is appropriate in ruling out organic causes of the symptoms presented by the client. Step 5: Psychological testing (Choice B) is more focused on assessing cognitive and emotional functioning, not ruling out organic pathology. Step 6: Immunologic assay (Choice C) is used to detect antibodies or antigens in the blood, not typically relevant in this context. Step 7: Dexamethasone suppression test (Choice D) is used to assess for abnormalities related to cortisol levels in conditions like depression, not specific to ruling out organic pathology in psychotic disorders. Summary: Choice A is correct because an MRI test is the most relevant
Question 4 of 5
A client on an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
Correct Answer: D
Rationale: The correct answer is D: Hold the medication and call the client's doctor immediately. This is the correct course of action because the client is exhibiting signs of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications. Holding the medication is essential to prevent further complications. Calling the doctor is necessary to inform them of the situation and seek further instructions. Administering the medication (choice A) would exacerbate the symptoms, giving a lower dose (choice B) is not sufficient in this emergency situation, and administering an anticholinergic (choice C) is not the appropriate response for NMS.
Question 5 of 5
A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating ______, and the nurse should ______.
Correct Answer: C
Rationale: The correct answer is C: akathisia"¦administer PRN diphenhydramine (Benadryl) PO. Akathisia is characterized by restlessness and an inability to sit still. Administering diphenhydramine can help alleviate these symptoms. A is incorrect because dystonic reactions present with muscle spasms and abnormal postures, not restlessness. B is incorrect as anxiety does not typically manifest as physical restlessness. D is incorrect as tardive dyskinesia involves involuntary movements of the face and body, not restlessness.