ATI RN
Classes of Psychotropic Medications Questions
Question 1 of 5
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:
Correct Answer: A
Rationale: The correct approach for a musculoskeletal assessment is to examine from proximal to distal. This means starting closer to the body's center and moving towards the extremities. This approach helps to assess for overall strength, range of motion, and joint stability before focusing on specific areas. By starting proximally, the nurse can establish a baseline assessment and then progress methodically to evaluate each joint and muscle group. This systematic approach ensures a comprehensive evaluation of the musculoskeletal system. Summary of Other Choices: B: Distal to proximal - This approach may miss important information about overall strength and stability. C: Posterior to anterior - This sequence is not ideal for a musculoskeletal assessment as it doesn't follow the natural flow of muscle and joint movements. D: Anterior to posterior - This order may not provide a holistic view of the musculoskeletal system and may lead to missing relevant findings.
Question 2 of 5
During the taking of the health history, a patient tells the nurse that 'it feels like the room is spinning around me.' The nurse would document this finding as:
Correct Answer: A
Rationale: The correct answer is A: Vertigo. Vertigo is a specific sensation of spinning or movement when there is no actual movement in the environment. This symptom is often associated with inner ear disorders. B: Syncope is a temporary loss of consciousness due to decreased blood flow to the brain. C: Dizziness is a general term that can encompass various sensations of lightheadedness, unsteadiness, or spinning. D: Seizure activity involves abnormal electrical activity in the brain, typically presenting with involuntary movements or altered consciousness.
Question 3 of 5
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
Correct Answer: D
Rationale: The correct answer is D: Positive Romberg sign. This finding indicates a positive Romberg test, which assesses proprioception and vestibular function. The patient swaying and widening his stance with eyes closed suggests a loss of balance control when visual input is removed. This can be indicative of sensory ataxia, a dysfunction in proprioception. Lack of coordination (choice B) is a broad term and does not specifically describe the patient's response. Ataxia (choice A) refers to a lack of muscle control during voluntary movements, not related to balance with eyes closed. Negative Homans sign (choice C) is a test for deep vein thrombosis in the lower extremities, not relevant in this case.
Question 4 of 5
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
Correct Answer: C
Rationale: The correct answer is C: Plantar reflex present. This is the correct documentation for observing plantar flexion of the toes during stroking of the sole. This response indicates a normal plantar reflex, also known as the Babinski reflex, in adults. A positive Babinski sign (choice A) would involve dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. Choice B (Plantar reflex abnormal) is incorrect because the observed plantar flexion is actually a normal response. Choice D (Plantar reflex 2+ on a scale from '0 to 4+') is not appropriate for documenting superficial reflexes.
Question 5 of 5
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
Correct Answer: C
Rationale: The correct answer is C because assessing the level of consciousness, motor function, pupillary response, and vital signs are crucial indicators of increased intracranial pressure after neurosurgery. Level of consciousness can indicate neurological changes, motor function may show signs of weakness or paralysis related to brain damage, pupillary response can reflect brainstem function, and vital signs can reveal changes in cerebral perfusion. Choice A is incorrect because it does not include vital signs, which are essential in monitoring for increased intracranial pressure. Choice B is incorrect as it does not cover pupillary response, which is a key indicator of brainstem function. Choice D is incorrect as it lacks the assessment of vital signs, which are vital in detecting changes in cerebral perfusion.