ATI RN
Psychiatric Emergency Questions
Question 1 of 5
The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the RN to take?
Correct Answer: D
Rationale: The correct answer is D: Redirect him by encouraging him to read from the handout. This is the best nursing action because it addresses the client's disruptive behavior by redirecting his focus back to the topic at hand, which is anger management. By encouraging him to read from the handout, the RN is helping the client engage in the intended activity and stay on track with the group session's purpose. This approach helps maintain the group's cohesion and ensures that all members benefit from the session. Exploring the client's feelings about his pets and home life (Choice A) may be relevant in a different context but is not the immediate priority in this scenario. Encouraging his peers to involve him in the activity (Choice B) may not effectively address his disruptive behavior. Giving the client permission to leave and return (Choice C) may disrupt the session and enable the client's avoidance of the activity.
Question 2 of 5
The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
Correct Answer: B
Rationale: The correct answer is B: Keep the client NPO after midnight. This is to prevent aspiration during the procedure, as ECT is typically performed under general anesthesia. Holding all bedtime medications (choice A) is not necessary unless specified by the healthcare provider. Implementing elopement precautions (choice C) is not relevant to ECT. Giving the client an enema at bedtime (choice D) is unnecessary and not indicated before ECT. Keeping the client NPO after midnight is a standard pre-procedure preparation to reduce the risk of aspiration.
Question 3 of 5
Which client statement suggests to the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
Correct Answer: B
Rationale: The correct answer is B because the client is attributing their presence in the psychiatric unit to external factors (police involvement) rather than acknowledging their own internal struggles. This aligns with the defense mechanism of projection, where individuals attribute their own thoughts or feelings onto others. Choice A demonstrates displacement, choice C shows rationalization, and choice D reflects denial, making them incorrect options.
Question 4 of 5
During the initial nursing interview, a client tells the nurse, 'Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?' Which documentation should the nurse use to describe the client's statements?
Correct Answer: C
Rationale: The correct answer is C: Exhibits tangential thinking. In this scenario, the client's statements lack logical connection and go off on tangents, such as thoughts about selling a car, work, and eating. This is characteristic of tangential thinking, where the individual struggles to maintain focus and coherence in their thoughts. Thought-blocking (A) refers to sudden interruption in the train of thought, incoherent speech (B) involves disorganized and unintelligible language, and word salad (D) is a severe form of incoherence where words are jumbled and meaningless. These choices do not accurately describe the client's statements in this context.
Question 5 of 5
The nurse in the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client's room in the morning and finds the client in bed. What intervention is best for the nurse to implement?
Correct Answer: A
Rationale: Correct Answer: A: Assist the client to get out of bed and involved in an activity. Rationale: 1. Depression often leads to social withdrawal and lack of motivation. 2. Encouraging activity helps combat physical and emotional stagnation. 3. Engaging in activity can boost mood and energy levels. 4. It promotes social interaction and prevents isolation. 5. Resting excessively may exacerbate depressive symptoms. In summary, Choice A is the best intervention as it addresses the client's need for activity, social interaction, and mood improvement, while the other choices do not actively address these aspects of care.