ATI RN
Multiple Choice Questions on Psychiatric Emergencies Questions
Question 1 of 5
Therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his best friend moved away. What is the best nursing intervention to support therapeutic Milieu?
Correct Answer: A
Rationale: The correct answer is A because encouraging activities that allow the patient to take control over his environment promotes empowerment and autonomy, which are essential for therapeutic milieu. This intervention helps the patient regain a sense of control and self-worth, fostering positive coping mechanisms. B: Providing constant supervision may make the patient feel restricted and monitored, impeding trust and therapeutic relationship. C: Limiting interactions with other clients may lead to feelings of isolation and lack of social support, which are crucial in therapeutic milieu. D: Administering sedative medications may address symptoms temporarily but does not address the underlying issues or promote active participation in the therapeutic process.
Question 2 of 5
An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to check the blood pressure first. Chest pain is a serious symptom that could indicate a cardiovascular issue. Checking the blood pressure will help determine if the chest pain is related to hypertension or a cardiac event. This step is crucial for immediate assessment and intervention. Administering nitroglycerin (Choice B) should only be done after assessing blood pressure to ensure it is safe to administer. Notifying the healthcare provider (Choice C) can be done after assessing the blood pressure to provide them with information for further guidance. Providing a quiet environment (Choice D) is not the priority when a client presents with chest pain.
Question 3 of 5
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle accident. The nurse includes in the plan of care to observe for signs of delirium tremens. Which early signs indicate that the client is beginning to have delirium tremens?
Correct Answer: A
Rationale: The correct answer is A: Restlessness and confusion. Delirium tremens (DT) is a severe form of alcohol withdrawal that can occur in individuals with a history of alcohol abuse. Early signs of DT include restlessness and confusion. This is due to the sudden cessation of alcohol intake, leading to overactivity of the central nervous system. Lethargy and bradycardia (choice B) are not typical signs of DT, as DT is characterized by hyperactivity of the CNS. Euphoria and hyperactivity (choice C) are also not indicative of DT, as DT is associated with agitation and confusion. Fever and seizures (choice D) can occur in severe cases of DT, but they are not typically early signs. Therefore, choice A is the correct answer as restlessness and confusion are early signs of delirium tremens.
Question 4 of 5
Patient taking Carbamazepine. Which action should the nurse take?
Correct Answer: A
Rationale: The correct action of obtaining a fingerstick glucose for a patient taking Carbamazepine is to monitor for hypoglycemia, a common side effect of the medication. This is crucial as Carbamazepine can lower blood sugar levels. Monitoring liver function tests (B) is not directly related to Carbamazepine use. Checking serum sodium levels (C) is not a priority unless the patient shows symptoms of hyponatremia. Assessing for signs of infection (D) is important but not specifically related to Carbamazepine use. Overall, obtaining a fingerstick glucose is the most appropriate action to monitor for potential side effects of Carbamazepine.
Question 5 of 5
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?
Correct Answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own anger and selfishness onto his roommate. By attributing these negative traits to someone else, the client avoids acknowledging and dealing with his own feelings. This defense mechanism helps protect his self-image and cope with uncomfortable emotions. Denial (A) involves refusing to accept reality, rationalization (C) involves justifying behavior with logical excuses, and splitting (D) involves seeing people as all good or all bad, which are not demonstrated in the scenario.