ATI RN
Target Healthcare Questions
Question 1 of 5
Which nursing diagnosis is a priority for both a patient with depression and one with acute mania?
Correct Answer: B
Rationale: The correct answer is B: Disturbed sleep pattern. Both depression and acute mania can disrupt sleep, leading to negative impacts on overall health. Sleep disturbances can exacerbate symptoms of both conditions and hinder recovery. Addressing sleep patterns is crucial in managing symptoms and improving outcomes for patients with depression and acute mania. A: Deficient diversional activity is more relevant to depression than acute mania, as patients with mania often engage in excessive activities. C: Fluid volume excess is not typically associated with depression or acute mania. D: Defensive coping may be relevant to both conditions but is not a priority compared to addressing sleep patterns for patient safety and symptom management.
Question 2 of 5
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (SHT2) excess will suggest that the client receive:
Correct Answer: C
Rationale: Rationale: Olanzapine (Zyprexa) is the correct choice because it is an atypical antipsychotic that targets serotonin receptors, particularly 5-HT2 receptors known to be involved in negative symptoms of schizophrenia like apathy, avolition, and blunted affect. Olanzapine's mechanism of action helps alleviate these symptoms by modulating serotonin levels in the brain. Incorrect Choices: A: Haloperidol and B: Chlorpromazine are typical antipsychotics that primarily target dopamine receptors and are less effective in treating negative symptoms associated with schizophrenia. D: Phenelzine is a monoamine oxidase inhibitor used to treat depression and anxiety disorders, not schizophrenia symptoms related to serotonin excess.
Question 3 of 5
A client tells the nurse, 'I hear people whispering about me. When I'm in the day room and they do that, I want to punch them.' The information the nurse should give to staff in report consists of which of the following?
Correct Answer: A
Rationale: The correct answer is A: "Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence." This response is appropriate because it emphasizes the importance of respecting the client's privacy and dignity by not discussing him or others in his presence. By being direct and matter-of-fact, the nurse can establish trust and build a therapeutic relationship with the client. This approach also helps maintain boundaries and avoids escalating the situation. Choice B is incorrect because avoiding the client may lead to feelings of rejection and worsen his symptoms. Choice C is incorrect because using touch without the client's consent may be inappropriate and could escalate the situation. Choice D is incorrect because speaking softly does not address the underlying issue of the client feeling threatened by whispering.
Question 4 of 5
A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia. Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
Question 5 of 5
A patient with schizophrenia begins to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. The term 'volmers' most likely represents:
Correct Answer: A
Rationale: The correct answer is A: a neologism. In schizophrenia, patients often create new words (neologisms) that have no meaning outside of their delusional context. The term 'volmers' is a made-up word by the patient, indicating a loss of touch with reality. Clanging (B) is a speech pattern characterized by rhyming or punning words, not creating new words. Anhedonia (C) refers to the inability to experience pleasure, unrelated to creating new words. Alogia (D) is a decrease in speech or thought productivity, not related to inventing new words. In this case, the patient's use of 'volmers' is indicative of a neologism associated with schizophrenia.