ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
The RN is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client's recovery?
Correct Answer: D
Rationale: The correct answer is D: Alcohol abstinence. For a client with alcoholic cirrhosis, the most crucial self-care measure is to completely stop alcohol consumption to prevent further liver damage and promote recovery. Alcohol is the primary cause of cirrhosis, so abstaining from it is essential. Support group meetings (A) can be beneficial but not as critical as stopping alcohol intake. Vitamin supplements (B) may help with nutritional deficiencies but do not address the root cause. A diet with adequate calories and protein (C) is important for overall health but cannot reverse the effects of alcohol-related cirrhosis.
Question 2 of 5
A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
Correct Answer: B
Rationale: The correct answer is B: Wishing to be with the deceased spouse. This statement indicates a desire for death or suicidal ideation, which is a critical concern that requires immediate exploration and intervention. The client may be at risk for self-harm or suicide. It is essential for the RN to assess the severity of this statement and ensure the client's safety. A: Not sleeping for several days - While important, this symptom may be related to grief and depression. However, it is not as urgent as assessing for suicidal ideation. C: Lack of interest in usual activities - Common in grief and depression, but does not indicate immediate risk of harm. D: Eating very little - Also common in grief, but not as urgent as assessing for suicidal ideation.
Question 3 of 5
An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
Correct Answer: D
Rationale: The correct answer is D: Assist the client to clean the walls. This action promotes therapeutic communication, maintains dignity, and encourages self-care. It allows the client to take responsibility for their actions and fosters a sense of autonomy. Choices A and B may be condescending and fail to address the behavior directly. Choice C may escalate the situation and jeopardize the therapeutic relationship.
Question 4 of 5
A client is admitted to the mental health unit and sits in the corner of the dayroom. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
Correct Answer: A
Rationale: The correct action for the nurse to implement is to attempt to ask the client simple questions (Choice A). By asking simple questions, the nurse can start building rapport with the client and gradually gain their trust. This approach can help the client feel more comfortable and open up during the assessment interview. It is important for the nurse to demonstrate patience, empathy, and understanding towards the client's guarded and suspicious behavior. Postponing the client interview until the next day (Choice B) may not address the client's current needs and may lead to further distrust. Asking another nurse to talk with the client (Choice C) may not necessarily be effective as the client may benefit from continuity of care with the same nurse. Documenting the client's paranoid behavior (Choice D) is important for the client's medical record but should not be the only action taken by the nurse in this situation.
Question 5 of 5
A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is C: Take other clients in the area to the client lounge. This intervention prioritizes the safety and well-being of both the agitated client and other clients in the unit. By removing other clients from the potentially escalating situation, the nurse can prevent further agitation or harm. This intervention also allows the client some space and privacy to calm down without an audience, potentially reducing their agitation. Incorrect choices: A: Transport the client to the seclusion room - This is a restrictive measure and should only be used as a last resort for safety reasons. B: Quietly approach the client with additional staff members - Approaching an agitated client may escalate the situation, especially if the client is refusing medication. D: Administer medication to chemically restrain the client - Chemical restraint should only be used as a last resort and must follow specific protocols and guidelines. It should not be the first intervention attempted.