ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 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 2 of 5
A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the nurse include to ensure the client is physiologically stable?
Correct Answer: A
Rationale: The correct answer is A: Monitor vital signs. This is crucial in managing a client with delirium tremens to ensure physiological stability. Monitoring vital signs such as blood pressure, heart rate, temperature, and respiratory rate can help identify any signs of deterioration or complications like dehydration, sepsis, or cardiovascular instability. By closely monitoring these parameters, the nurse can intervene promptly and prevent any further complications. Summary: - Option B is incorrect because administering antipsychotic medication is not the priority in managing delirium tremens. - Option C is incorrect as providing a quiet environment may help with managing hallucinations, but it does not address the physiological stability of the client. - Option D is incorrect as encouraging fluid intake is important for hydration but does not address the need for monitoring vital signs to ensure physiological stability.
Question 3 of 5
The nurse goes to answer a call light, and the patient is aggressive and agitated. What is most important for the nurse to do?
Correct Answer: A
Rationale: The correct answer is A: Stay in the doorway. By staying in the doorway, the nurse maintains a safe distance from the aggressive and agitated patient, reducing the risk of harm to both the nurse and the patient. Approaching calmly (B) may escalate the situation. Administering sedative medication (C) without assessing the situation further can be dangerous. Calling for additional staff assistance (D) is important, but the immediate priority is ensuring safety by staying in a safer position.
Question 4 of 5
Patient with schizophrenia enters the psychiatric unit with symptoms. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the medication list. This is crucial as patients with schizophrenia often take antipsychotic medications that help manage their symptoms. Checking the medication list ensures the patient is receiving the appropriate treatment and dosage. Assessing for signs of infection (B) and monitoring vital signs (C) are important but not the priority in this case. Providing a quiet environment (D) is beneficial for patients with schizophrenia, but checking the medication list takes precedence to ensure proper treatment.
Question 5 of 5
The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
Correct Answer: D
Rationale: The correct answer is D: Nausea and vomiting. Lithium is known to cause gastrointestinal side effects, such as nausea and vomiting, which can potentially indicate toxicity. The RN should report this immediately to the healthcare provider as it could be a sign of lithium toxicity, which can be life-threatening. A: Short-term memory loss is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. B: Five-pound weight gain is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. C: Decreased affect is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting.