ATI RN
PICO Question Psychiatric Emergency Nursing Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve?
Correct Answer: B
Rationale: Rationale: Option B is the correct choice because it adheres to a tyramine-restricted diet. Mashed potatoes, ground beef patty, corn, green beans, and apple pie are all low in tyramine. Tyramine is found in aged, fermented, and pickled foods, as well as in certain fruits and vegetables. The other options contain foods high in tyramine: hot dogs, banana bread, caffeinated coffee (Option A); avocado, ham, chocolate cake (Option C); and smoked sausage, cheddar cheese, and yeast rolls (Option D). Therefore, Option B is the best choice for a tyramine-restricted diet.
Question 5 of 5
A patient diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?
Correct Answer: A
Rationale: The correct answer is A: Make observations. This technique is effective because it allows the nurse to show nonjudgmental acceptance and support without pressuring the patient to engage in lengthy conversations. By making observations, the nurse can acknowledge the patient's behavior without requiring a response, thus respecting the patient's need for space and limited interaction. Option B: Asking the patient direct questions may feel intrusive and overwhelming for someone with major depressive disorder who is withdrawn. Option C: Phrasing questions to require yes or no answers limits the patient's ability to express themselves fully and may not promote a sense of support and acceptance. Option D: Frequently reassuring the patient to reduce guilt feelings may come across as insincere or patronizing, and may not address the patient's need for nonjudgmental acceptance in communication.