ATI RN
Classes of Psychotropic Medications Questions
Question 1 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 2 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.
Question 3 of 5
A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:
Correct Answer: C
Rationale: Step 1: Rapid alternating movements inability is characteristic of dysdiadochokinesia. Step 2: Dysdiadochokinesia is the inability to perform rapid alternating movements due to cerebellar dysfunction. Step 3: Ataxia is a general term for lack of coordination but does not specifically refer to rapid alternating movements. Step 4: Astereognosis is the inability to recognize objects by touch, not related to rapid alternating movements. Step 5: Loss of kinesthesia is the loss of ability to sense body position and movement but does not specifically involve rapid movements. Summary: Choice C is correct as it directly relates to the patient's inability to perform rapid alternating movements. Choices A, B, and D are incorrect as they do not specifically address the patient's symptom.
Question 4 of 5
The nurse is assessing the vital signs of a 78-year-old patient. His temperature is 36.5°C (97.7°F), pulse is 90 beats per minute, respiratory rate is 18 breaths per minute, and blood pressure is 138/80 mm Hg. The nurse notices that the patient is slightly confused and asks the nurse if she can help him with anything. The nurse should:
Correct Answer: D
Rationale: The correct answer is D. 1. Monitoring for changes in the patient's condition is crucial to identify any deterioration or improvement. 2. Assessing for dehydration or infection is important as these conditions can cause confusion in elderly patients. 3. Rechecking vital signs may not provide additional information if they are within normal limits. 4. Obtaining a complete neurologic examination is not necessary at this point as the patient's confusion may be due to a more common cause like dehydration or infection. 5. Administering a sedative to relieve confusion is not appropriate without identifying and addressing the underlying cause. In summary, option D is the best course of action as it focuses on monitoring the patient's condition, assessing for potential causes of confusion, and addressing any underlying issues.
Question 5 of 5
The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment?
Correct Answer: C
Rationale: Rationale: Choice C is correct because it directly addresses circadian rhythms by asking about the patient's best and worst times of day, which helps assess their sleep-wake cycle disturbances common in depression. Choices A and D focus on hallucinations and cognitive functioning, not circadian rhythms. Choice B is related to memory impairment, not circadian rhythm disturbances.