ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 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.
Question 2 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 3 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 4 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.
Question 5 of 5
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
Correct Answer: D
Rationale: The correct answer is D: Escort the client to his room. This intervention is best because it addresses the behavior causing disturbance without isolating the client or administering unnecessary sedatives. By escorting the client to his room, the nurse provides a supportive and non-punitive approach to managing the behavior. It allows the client to have a quiet space to calm down, reducing the annoyance to other clients. Isolating the client may worsen the behavior or create feelings of abandonment. Administering a sedative should be avoided unless absolutely necessary to ensure client safety. Avoiding recognizing the behavior does not address the issue or provide any support to the client.