ATI RN
Classes of Psychotropic Medications Questions
Question 1 of 5
During the taking of the health history, a patient tells the nurse that 'it feels like the room is spinning around me.' The nurse would document this finding as:
Correct Answer: A
Rationale: The correct answer is A: Vertigo. Vertigo is a specific sensation of spinning or movement when there is no actual movement in the environment. This symptom is often associated with inner ear disorders. B: Syncope is a temporary loss of consciousness due to decreased blood flow to the brain. C: Dizziness is a general term that can encompass various sensations of lightheadedness, unsteadiness, or spinning. D: Seizure activity involves abnormal electrical activity in the brain, typically presenting with involuntary movements or altered consciousness.
Question 2 of 5
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
Correct Answer: C
Rationale: The correct answer is C: Plantar reflex present. This is the correct documentation for observing plantar flexion of the toes during stroking of the sole. This response indicates a normal plantar reflex, also known as the Babinski reflex, in adults. A positive Babinski sign (choice A) would involve dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. Choice B (Plantar reflex abnormal) is incorrect because the observed plantar flexion is actually a normal response. Choice D (Plantar reflex 2+ on a scale from '0 to 4+') is not appropriate for documenting superficial reflexes.
Question 3 of 5
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
Correct Answer: C
Rationale: The correct answer is C because assessing the level of consciousness, motor function, pupillary response, and vital signs are crucial indicators of increased intracranial pressure after neurosurgery. Level of consciousness can indicate neurological changes, motor function may show signs of weakness or paralysis related to brain damage, pupillary response can reflect brainstem function, and vital signs can reveal changes in cerebral perfusion. Choice A is incorrect because it does not include vital signs, which are essential in monitoring for increased intracranial pressure. Choice B is incorrect as it does not cover pupillary response, which is a key indicator of brainstem function. Choice D is incorrect as it lacks the assessment of vital signs, which are vital in detecting changes in cerebral perfusion.
Question 4 of 5
A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:
Correct Answer: C
Rationale: Step 1: Rapid alternating movements inability is characteristic of dysdiadochokinesia. Step 2: Dysdiadochokinesia is the inability to perform rapid alternating movements due to cerebellar dysfunction. Step 3: Ataxia is a general term for lack of coordination but does not specifically refer to rapid alternating movements. Step 4: Astereognosis is the inability to recognize objects by touch, not related to rapid alternating movements. Step 5: Loss of kinesthesia is the loss of ability to sense body position and movement but does not specifically involve rapid movements. Summary: Choice C is correct as it directly relates to the patient's inability to perform rapid alternating movements. Choices A, B, and D are incorrect as they do not specifically address the patient's symptom.
Question 5 of 5
The nurse is assessing the vital signs of a 78-year-old patient. His temperature is 36.5°C (97.7°F), pulse is 90 beats per minute, respiratory rate is 18 breaths per minute, and blood pressure is 138/80 mm Hg. The nurse notices that the patient is slightly confused and asks the nurse if she can help him with anything. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. 1. Monitoring for changes in the patient's condition is crucial to identify any deterioration or improvement. 2. Assessing for dehydration or infection is important as these conditions can cause confusion in elderly patients. 3. Rechecking vital signs may not provide additional information if they are within normal limits. 4. Obtaining a complete neurologic examination is not necessary at this point as the patient's confusion may be due to a more common cause like dehydration or infection. 5. Administering a sedative to relieve confusion is not appropriate without identifying and addressing the underlying cause. In summary, option D is the best course of action as it focuses on monitoring the patient's condition, assessing for potential causes of confusion, and addressing any underlying issues.