ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 of 5
Patient with alcoholic withdrawal symptoms who says she has snakes all over her body. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer PRN Lorazepam (Ativan). This is because the patient is experiencing hallucinations, a common symptom of alcohol withdrawal. Lorazepam is a benzodiazepine that can help reduce anxiety and manage hallucinations effectively in this situation. Providing a quiet environment (B) may be helpful, but addressing the hallucinations is the priority. Offering fluids and snacks (C) and reassuring the client (D) do not directly address the underlying issue of hallucinations and may not provide adequate relief for the patient's distress.
Question 2 of 5
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone. When the client walks to the nurse station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed anticholinergic Benztropine (Cogentin) for dystonia. In this scenario, the client's presentation of walking in a laterally contracted position and attributing it to something external causing his body to contort into a monster is indicative of acute dystonia, a side effect of antipsychotic medications like Risperidone. Administering Benztropine, an anticholinergic medication, helps alleviate dystonic symptoms by blocking the effects of excess acetylcholine in the brain. It is important to address dystonic symptoms promptly to prevent further distress and potential complications. Incorrect choices: B: Reassuring the client that the sensation is temporary does not address the underlying cause of the symptoms and may lead to increased distress. C: Encouraging the client to relax and breathe deeply may not effectively manage the acute dystonic symptoms and could delay proper treatment. D: While documenting the client's symptoms and notifying
Question 3 of 5
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the RN?
Correct Answer: A
Rationale: The correct answer is A because attempting to physically restrain the client can escalate the situation and potentially harm the client or the mental health worker. Restraints should only be used as a last resort and under the guidance of a healthcare professional. Choice B is not ideal as it may not effectively de-escalate the situation. Choice C may further agitate the client. Choice D is not the most critical concern at the moment compared to physical restraint.
Question 4 of 5
Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing action?
Correct Answer: A
Rationale: The correct answer is A because safety of other clients is the priority. Moving other clients to another room ensures their well-being and respects their privacy. Administering sedative medication (B) should be a last resort and requires consent. Confronting the client (C) may escalate the situation. Ignoring the behavior (D) neglects duty of care.
Question 5 of 5
The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms the assessment?
Correct Answer: A
Rationale: The correct answer is A because it reflects a paranoid delusion where the client believes the nurse is trying to harm him. This statement confirms the client's distorted perception of reality, a common feature of paranoid schizophrenia. Option B shows denial of illness, not delusional thinking. Option C involves persecution delusion but does not confirm the assessment. Option D indicates auditory hallucinations, not delusions. Therefore, A is the correct choice as it directly aligns with the client's paranoid delusional beliefs.