ATI RN
Psychiatric Emergency Questions
Question 1 of 5
The nurse is assessing the client in a fugue state. What assessment findings would the nurse recognize as most significant to experiencing a fugue state?
Correct Answer: D
Rationale: The correct answer is D because a recent history of severe trauma is most significant to experiencing a fugue state. Fugue state is often triggered by severe trauma or stress, causing a person to temporarily lose their sense of identity and wander aimlessly. Choice A, depersonalization, is more related to dissociative disorders rather than fugue state. Choice B, depressive symptoms, may be present but are not specific to a fugue state. Choice C, childhood trauma, may contribute to dissociative disorders but is not directly linked to experiencing a fugue state. Therefore, the recent history of severe trauma is the most relevant assessment finding in this scenario.
Question 2 of 5
At which point would the nurse determine that a client is at risk for developing a mental illness?
Correct Answer: B
Rationale: Step 1: Mental illness involves maladaptive responses and interference in daily functioning. Step 2: Maladaptive responses + interference = risk for mental illness. Step 3: Choice B states maladaptive responses + interference, aligning with the risk factors for mental illness. Summary: Choices A, C, and D do not specifically address the key factors of maladaptive responses and interference in daily functioning, which are crucial indicators of being at risk for developing a mental illness.
Question 3 of 5
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I'm here for my heart, not my head problems.†Which is the nurse's best response?
Correct Answer: C
Rationale: The correct answer is C because it provides a logical and evidence-based explanation for why psychosocial questions are relevant to the client's heart condition. By highlighting the connection between psychological factors and medical conditions, the nurse can help the client understand the importance of addressing both aspects for optimal health outcomes. Choice A is incorrect as it simply dismisses the client's concerns without providing a meaningful explanation. Choice B is incorrect as it fails to address the client's resistance and may come off as confrontational. Choice D is incorrect as it undermines the significance of psychosocial questions in the assessment process.
Question 4 of 5
When under stress, a client routinely uses alcohol to excess. When the client's husband finds her drunk, the husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client's use of the defense mechanism of denial?
Correct Answer: D
Rationale: The correct answer is D because the client's statement "I don't drink too much!" directly reflects denial, a defense mechanism where individuals refuse to accept reality to protect themselves from uncomfortable truths. This response shows the client's refusal to acknowledge their excessive alcohol use despite clear evidence. A is incorrect because hiding liquor bottles indicates deception, not denial. B is incorrect as yelling at her son for slouching is displacement, not denial. C is incorrect as burning dinner on purpose demonstrates passive-aggressive behavior, not denial. In summary, only answer D directly showcases denial as a defense mechanism in response to the husband's confrontation about alcohol abuse.
Question 5 of 5
A 55-year-old man presents with suicidal ideation. He tells you that he 'was just laid off from his job' after only 3 months, and that his 3 children 'want nothing to do with him' because he 'wasn't really involved in their childhoods'. He feels hopeless and useless. Which of Erikson's stages describes this man's difficulties?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.