ATI RN
Multiple Choice Questions on Psychiatric Emergencies Questions
Question 1 of 5
The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, 'I don't need to be here' and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam?
Correct Answer: B
Rationale: The correct answer is B: Insight and judgement. In this scenario, the client's statement "I don't need to be here" reflects insight, the ability to recognize one's own condition. Additionally, the belief that the television talks to her indicates impaired judgement, as it is a sign of a psychotic symptom. Both insight and judgement are crucial components of mental status evaluation, as they provide important information about the client's awareness and decision-making abilities. A: Level of concentration is not directly related to the client's statements about her need to be hospitalized or the belief about the television. C: Remote memory refers to the ability to recall past events, which is not being assessed by the client's current statements. D: Mood and affect pertain to emotional state, which is not the primary focus of the client's statements in this case.
Question 2 of 5
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, 'I can't believe this. What should I do?' Which response is best for the RN to provide in this crisis?
Correct Answer: D
Rationale: The correct answer is D: Call for transportation to the hospital. This response is the best because it addresses the immediate need for the employee to be with her child at the hospital. Providing transportation shows support and helps the employee to take action quickly. A: Tell me what you think should happen - This response puts the onus on the employee to make a decision when she is in a crisis situation, which may not be the most helpful approach. B: How serious was the collision? - While showing concern, this response does not address the immediate need for the employee to be with her child at the hospital. C: What do you think you should do? - Similar to choice A, this response also shifts the responsibility to the employee and may not be the most supportive in a crisis.
Question 3 of 5
The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
Correct Answer: A
Rationale: The correct answer is A: Don't allow the client to go into the kitchen until the hallucination has subsided. This intervention is crucial to ensure the client's safety as it helps prevent harm to himself or others. Allowing the client access to a potential weapon during a hallucination could result in serious injury. By restricting access to the kitchen, the RN can mitigate the risk and provide a safe environment for the client. Summary of other choices: B: Reporting to the client's case workers may be important, but the immediate safety of the client takes precedence. C: Assigning the UAP is not sufficient to address the safety issue at hand, as direct intervention by the RN is needed. D: While documenting the behavior is important, immediate action to prevent harm is more critical in this situation.
Question 4 of 5
A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zyprexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?
Correct Answer: A
Rationale: The correct answer is A: Weight gain of 75 lbs. Olanzapine is known to cause significant weight gain as a common side effect. This is due to its impact on appetite control and metabolic processes. Other choices are less likely to be directly related to olanzapine. B, thoughts of wanting to hurt himself, is a serious side effect of olanzapine but not as common as weight gain. C, frequent days with diarrhea, is not a typical side effect of olanzapine. D, altered liver function tests, is a possible side effect of olanzapine but weight gain is more commonly associated with it.
Question 5 of 5
A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?
Correct Answer: D
Rationale: The correct answer is D: Assess and report the client's electrolyte status to the healthcare provider. This is the highest priority because electrolyte imbalances are common in clients with bulimia nervosa due to purging behaviors. Monitoring electrolytes is crucial to prevent life-threatening complications. A: Scheduling group therapy may be beneficial, but addressing the physical health concern is the priority. B: Assigning care based on age is not essential in this situation. C: Monitoring for binging activities is important but not as critical as assessing electrolyte status. In summary, ensuring the client's physical health and safety by monitoring electrolyte status is the top priority in managing a client with bulimia nervosa.